Factors that Influence Caregivers’ Recommendations
Article Under Construction…
When
making treatment recommendations, there are several factors that a physician,
midwife, nurse, or hospital administration must take into account. From an expectant
parent’s perspective, the only important factors in any pregnancy-related
decision are: the health and well-being of the baby and of the mother. From a
caregiver’s perspective, the well-being of baby and mother is the primary goal; however, other issues also come into play.
Occasionally,
you may hear someone bad-mouthing a physician, saying that she recommended
c-section because then she would make more money, or that he gave a mom Pitocin
to speed up her birth so he could make his tee time at the golf course. My
intention here is not to criticize
any caregiver by what I write. Yes, in any professional field, there could be a
few bad apples, who would prioritize their golf game.
However, I believe those caregivers to be rare, and I believe that most
caregivers do their absolute best to weigh all the factors, and make the
decision they truly believe to be best for all involved.
That
said, I think it’s vital to explore what factors they are weighing, and exactly
who “all involved” parties are. Having an understanding of this can help
expectant parents to make truly informed decisions.
Malpractice
Insurance
Obstetricians
have seen massive increases in the costs of malpractice insurance in recent
years. For example, in
Liability
/ Fear of Lawsuits
Obstetricians
have particular reason to fear malpractice suits. 77 percent of obstetricians
have been sued, and the typical OB-GYN can expect to be sued 2.5 times during
his career. The median award for medical negligence in childbirth cases was
$2.1 million in 2001. 1 Clearly, there are cases of medical negligence,
and there are children and families who will suffer because of an error by a
physician (and, ironically, it’s estimated that 83 – 97% of patients who do
suffer injury due to negligence never file a lawsuit). 2
However, also clearly, there are numerous frivolous lawsuits each year; there
are also attorneys who aggressively pursue parents of
handicapped infants to encourage them to sue, whether or not the physician was
at fault: as many as 80% of malpractice claims are found to be without merit,
but it takes an average of $25,000 and three years to defend each of those
claims. 3
Obviously,
this creates a climate of fear and antagonism which can effect a physician’s
care recommendations. ACOG surveys have suggested that "fear of lawsuit"
is the major rationale for many obstetrical procedures. 4 A 2002 Harris survey of physicians found that
because of fear of liability: 79% order unnecessary tests, 74% make unnecessary
referrals, 51% suggest unnecessary biopsies, and 41% say they prescribe
unnecessary antibiotics. 76% say their concerns about litigation have hurt
their ability to provide quality patient care.
An example of this situation: Electronic fetal heart rate
monitoring is used in over 75% of deliveries in the
To
learn more, read “Improving Health Care Quality and Lowering Costs by Fixing
Our Medical Liability System” by the Department of Health and Human
Services.
Hospital
Policy / Legal Priorities
Just as malpractice insurance costs and litigation concerns
affect individual physicians, they also affect hospital policies and procedures.
Also, insurance reimbursement is a huge issue for hospitals, and that affects
their policies. Consumer demand also plays a role. Policies such as routine
fetal monitoring, no food in labor, mandatory antibiotics for Group B Strep,
and shortened postpartum hospital stays have their roots in many issues beyond
simply what is best for the health of mom and baby. Once a policy is
established, all caregivers at the hospital must follow that policy, and must
base their recommendations on what is allowed at the facility where the birth
will take place.
There are times when a physician disagrees with a hospital
policy, but must follow it in order to retain privileges at the hospital. There
are times when legal requirements may go against a physician’s best medical
judgment, yet, he is required to follow the law. Within the AMA Principles of Ethics, physicians are told to
respect the law, but also then to become advocates for their patients and
“recognize a responsibility to seek changes in those requirements which are
contrary to the best interests of the patient.”
Ethical
issues
Obstetrical
caregivers often confront ethical dilemmas that they must resolve internally in
order to make a care recommendation. For most caregivers, they eventually
determine their own set of guiding principles for most situations that could
arise. Sometimes there is no clear “right answer”, and different caregivers
might give different recommendations for the exact same situation.
Sometimes
the ethical dilemmas become overwhelming. I knew a caregiver who was working in
neonatal intensive care, and eventually had to leave the field, because as she
said “we can save the lives of virtually any baby these days. But some of these
babies will have huge, on-going health challenges the rest of their lives,
which will cause the whole family to struggle along. And I just don’t know what
the right answer is in those cases.” Here’s an interesting article that shows all the sides of this ethical
dilemma.
Caregiver’s
Convenience:
Caregivers are all human beings, who, like all of us, have a
desire to spend time with their families, get together with friends, fit in a
workout routine, and enjoy an occasional vacation. Everyone who enters the
profession of obstetrics, midwifery, or doula work, has to accept the fact that
labor and birth are inherently unpredictable. They acknowledge that their
professional obligations will occasionally interfere with other obligations:
for example, when a client goes into labor three weeks early with a long and
complicated labor… on your child’s birthday. These conflicts are part of the
job, and you often have no choice in the matter.
However, there are times when there are choices to be made. And when the caregiver is weighing
all the factors that go into the decision, they can’t help but take into
account their own needs. For example, if, based on all available information, a
physician believes an induction will be medically necessary sometime in the
next three or four days, but that it doesn’t seem to make a medical difference
whether it is on Friday or Saturday, most physicians would choose Thursday
night or Friday, in hopes of spending the weekend with their kids.
It’s clear that this pattern does happen. “Data from the
Centers for Disease Control (CDC) show induction of labor in the
Is inducing on Friday justifiable and ethical if a physician
truly believes that induction is medically necessary, and that all other factors are equal, and that
inducing on Friday instead of Saturday will do no harm? Yes. Is it ethical for
a physician to recommend a Friday induction if it is only for his/her
convenience and not medically indicated? Probably not.
Research shows that there are significant risks associated with purely elective
inductions, and many people question the ethics of convenience inductions.
Do parents have a right to question a doctor’s recommendation to understand
whether convenience was a factor in making that decision? Yes.
From
Here Down is Rough Draft
Caregiver’s
Lack of Knowledge
A
conscientious physician makes every effort to constantly expand their knowledge
base, and stay informed of all the information relevant to their practice.
Unfortunately, the vast quantity of information they are
Lack of training. Sometimes a physician lacks
knowledge because their medical training did not cover some vital topics. Dr.
Andrew Weil reports that in his entire time at medical school, he received
thirty minutes of training in nutrition. Many practicing pediatricians have
little to no training in breastfeeding support. Some may have received just
enough training to feel like they know what they need to know, and may be
over-confident in the accuracy of the information they are giving.
Their self-confidence was inappropriately high, with 49% of the total sample describing themselves as "confident" or "very confident" to manage common breast-feeding problems. Female residents had a higher confidence level than male residents. Although high in self-confidence about breast-feeding, the residents in this study were not knowledgeable about breast-feeding management, answering only 38% of the questions correctly. This study showed that residents in obstetrics do not have the basic skills, even at the end of training, to help mothers successfully maintain breast-feeding. Key promotional interventions linked to obstetricians' attitudes and practices have been shown to influence infant feeding choices.13 Thus, this study suggests the confidence and attitudes of obstetric residents toward breast-feeding are based on superficial knowledge of breast-feeding 8 Regarding preparation for breast-feeding counseling, more than 50% of all practicing physicians rated their residency training as inadequate. 9 only 64% of practitioners and 52% of residents knew that supplementing during the first few weeks of life may cause breast- feeding failure. 10
The
In a recent study by Schanler
and his associates (1999), a survey of 1137 active fellows of the
Finding a doctor who will support you with breastfeeding.
Patients access to medical information.
Patients now routinely arrive at doctors with stacks of printouts from the web.
…”knew more about that topic
than his primary care physicians did (and perhaps some [specialists] as
well)." Even as the Internet allows patients access to information
previously only available through their doctors, patients still trust the information
they get from their doctors more than they do from Web sites, current surveys
suggest. Because of this, doctors may fill the role of advisers or consultants,
helping patients not only sort through the information that is available, but
make rational decisions based on that information. 12
List of
resources for you to inform your doctor of where they can get more basic
information on breastfeeding and how physicians can support it.
Information Overload. “The
information environment faced by physicians has undergone a radical
transformation over the past decade, with the emergence of profiling,
guidelines, online information systems, and many other novel sources of
information… The study shows that the current environment is rich with
diversity, yet highly chaotic. There is more information available, in more formats
than ever before, competing for the limited time that physicians have to keep
abreast of changes in the medical world. The electronic information age is
slowly transforming this landscape, but has not yet delivered tools that can
reliably and sensibly alleviate the information overload faced by many
physicians…. Consequently, it appears that much of the information being distributed is
not being fully absorbed by physicians….To capture the attention of physicians
effectively without using payment as leverage, information must be timely,
relevant, authoritative, and easily accessible. Physicians are more likely to act on information
if there is a monetary incentive involved, and to screen out information from
questionable sources, highly complex data, and voluntary guidelines. Link
Caregiver’s
Beliefs
Public
Health
In the case of childhood immunizations, their benefit it not just for
the child receiving the shot, but also for the community at large.
However,
there is controversy and debate over which illnesses we most need to protect
our children and our communities from, and at what age they should be immunized
for various illnesses. Hepatitis B is an especially curious case. Hepatitis B
is a blood-borne illness, primarily transmitted by sexual intercourse, and IV
drug use. It is generally not an illness that children are at risk of
contracting (unless their mothers have it). So, why do we immunize babies for
Hepatitis B? Because high-risk groups like IV drug abusers don’t tend to come
to clinics for voluntary vaccinations, but parents of babies tend to take the
responsibility for bringing their baby in for the recommended immunizations."Infants
are considered the easiest to immunize, said Dr. Walter Ornestein,
directory of the National Immunization Program at the C.D.C." [Lining Up
for Hepatitis Shots, NY Times, July 30, 1997.]
Money
For a
look at how all these issues can play out in health recommendations, check out
a fascinating article that looks at Immunizations: Vaccine FAQ
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