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Wednesday
Jan262011

Article Round-up: Early Inductions, Practice Variation and Baby-Snatching

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By Jill Arnold

 

An assortment of articles I’ve read recently. Pardon the lack of rhyme or reason.

 

This ABC News article covers NYU School of Medicine’s new, patient-centric Curriculum for the 21st Century, which has students shadow patients rather than doctors.

NYU’s Abramson said, “It’s very nice to have a doctor that you love and who puts an arm around you, but not if that doctor makes bad medical decisions.

“Compassion is important but compassion without competence is not a virtue.”

A doctor may see up to 30 patients a day. But every visit — no matter how short — is an opportunity to show empathy, Abramson said.

 

 

Dr. Zachary Meisel’s article, Googling Symptoms Helps Patients and Doctors, on Time.com attracted the attention of patient advocates and bloggers last week.

But to debate whether patients should or should not Google their symptoms (which a surprising number of doctors seem to enjoy engaging in) is an absurd exercise. Patients already are doing it, it is now a fact of normal patient behavior, and it will only increase as Internet technology becomes ever more ubiquitous. The average Joe has more health information at his fingertips — both credible and charlatan — than all the medical libraries ever built put together. So the real question is, What can professionals do to translate this phenomenon into better health for their patients and the public?

 

 

The Leapfrog Group, a non-profit organization that compares hospitals on national standards of safety and quality, asked hospitals to voluntarily report their rate of elective deliveries before 39 completed weeks of pregnancy. The hospital’s rate of elective deliveries is the percentage of non-medically indicated (without a medical reason) births between 37 and 39 weeks gestation, that were delivered by caesarean section or induction.

Hospital rates of elective deliveries are listed by state here.

 

 

Childbirth Connection published a new section titled Induction of Labor today, which covers:

How can I make sense of what I hear about induction of labor?

What normally causes labor to begin?

What is the safest point in pregnancy for the baby to be born?

Why are so many women experiencing induced labor?

 

 

Dave deBronkart, patient advocate and contributor to Defending Ourselves against Defensive Medicine, blogged “Practice variation”: an essential e-patient awareness topic last month, listing the following as his nutshell version of the issue (Note: I botched his sub-bullets. See original post.):

Very large parts of healthcare are delivered inconsistently from area to area.

In other words, the care you get depends on where you live.

That’s right; very often, care decisions aren’t based on some objective standard of care. The same patient in a different local area might or might not get a prescription for treatment. Very often.

Which one is right? Is one overtreated, or is the other undertreated?

This isn’t a matter of economics: it’s a matter of local medical practice. It cuts across all economic levels.

That’s why it’s not called discrimination, it’s called practice variation.

The people involved – the doctors – mostly don’t know they’re doing it.

Bottom line: depending on where you live, you may be getting care you don’t need – hospitalizations and even surgery.

Since both of those carry risks of infection and even death, e-patients need to be aware so they can make informed, empowered choices.

 

 

Someone (thanks, Laura) sent me a year-old post on Slate titled Invasion of the Baby-Snatchers: Our irrational fear of infant abduction could be causing real harm, which is making the rounds again after the recent confession to abduction of a newborn from a New York hospital in 1987. Nestled within the article is a fascinating take on managed care in the 80’s, marketing directly to the consumer and the proposed remedy for a fear of a problem rather than an actual problem.

So if baby-snatching was never much of a problem to begin with, why are health care administrators across the country so focused on its prevention? The history of the panic—with its abrupt beginning in the late 1980s and gradual inflation over the following decade—mirrors a broader shift in the medical industry. Hospitals now advertise their services directly to the public, and their efforts are directed, first and foremost, at the most valuable health care demographic: young, pregnant women.

The idea that patients might be wooed with perks and gimmicks emerged in the 1980s and 1990s with the rise of managed care. The size and scope of HMOs helped insurance companies squeeze lower rates from the providers. (“Cut your prices, or you’re out of the network.”) So the hospitals were forced into a more aggressive posture: They stayed in business by actively recruiting customers.

From the beginning, women of child-bearing age were central to the business plan. Maternity wards provided a steady source of revenue in uncertain times. But it wasn’t the babies the industry was after so much as the moms. Studies showed that women were responsible for 60 to 80 percent of the health care decisions for their entire families. If you could get a young woman into your hospital when she was just starting a family, you’d have a shot at locking down four or five customers for life.

So began the “Maternity Wars.” Birth centers across the country were renovated and ramped up to attract market share, and the maternity ward started to resemble a luxury hotel. Hospitals advertised single-occupancy rooms with flat-screen TVs, plush bathrobes, and deep Jacuzzi tubs. (The unspectacular New York City hospital where I was born in the 1970s now sports Italian glass tile, elegant sconces, and decorative mirrors.) Once all these perks were in place, enhanced infant security was a logical next step. Come for the lakeside views, the fresh-baked cookies, and the motion-activated surveillance cameras …

 

 

 

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Reader Comments (14)

I have often wished that every aspiring ob/gyn would be trained and work as a doula first.

I agree, Rebecca. I also think OB training programs should encourage their students to respectfully shadow midwives, especially homebirth midwives. I think every medical student should see that side of birth, whether they end up in obstetrics or not.

January 27, 2011 | Unregistered CommenterAugusta

I agree that safety of both mother and baby should always be our first concern. Still, I believe that the increasing rate of induced labors is not something that should be taken lightly.

Lena Leino,
author Easier, Shorter, and Safer Birth

January 27, 2011 | Unregistered CommenterLena Leino

From the baby snatching article:

<<These are awful, terrifying crimes, but a few grisly news reports needn't make us panic any more than we already have. Real-life infant abductions (and baby switches) are freak events, affecting an infinitesimal subset of the population. That doesn't mean we shouldn't make smart choices to minimize tiny risks. Footprinting and ID bracelets offer sensible and appropriate protection against unlikely mistakes. But a consumer-minded, zero-tolerance policy that pushes for high-tech alarm systems isn't saving any lives. The real problem here is the handful of baby-snatchers who will always live among us, desperate and insane. These women will find their opportunities, one way or another—and they won't be deterred by the "Cuddles with Kisses" system in the maternity ward. We have an obligation to keep babies and mothers safe, but the frenzy over infant abduction isn't helping.>>

Finally, some sense. Now, if we could just have some of that same sense applied to our thinking about labor and delivery, we might be getting somewhere (along the lines of Dr Amy's analysis of the risk culture). Risk is everywhere, and it's up to each of us to decide which set of risks to accept.

I also found the discussion of hospital marketing intersting. Not only does it help me with my cognitivie dissonance over the fact that hospitals *seem* to be worried about homebirthers taking away from their $$ base (although I still have some dissonance over this, based on the very small numbers of homebirthers there are), but it further increases my feeling that managed care has done little good and lots of damage to the medical profession and patient care....unless increased prices automatically mean better care (I think we'd almost all agree that's not the case in any area of specialty). All this money spent on cozy rooms and high-tech machines for birth and security. There's a fairly simple solution...have rooming in and normal security (guards, etc.). When all babies are under the watchful eye of their parent/mother, it is going to be hard for them to be switched or snatched. I wonder if standard rooming-in would be as or more effective, and more economical, than these high tech gadgets....and it would facilitate bonding and breastfeeding as well, added bonus. I'd rather have a plain, dreary hospital room with hands-off-except-when-absolutely-necesssary staff and rooming in, than have all the bells and whistles and pay out the nose. It's true...having a homey environment is nice, but generally home/NCB birthers don't care nearly as much about that as they do about other things (at least in my experience).

The other point I always make...and it applies to in-hospital security systems as well as a wall on our border that some would like to see built - is that anything built/installed to keep people out, can also be used to keep you in. Again, not likely...but I would bet it happens as much as the baby snatching. From my perspective, in many cases, things done for our *safety* often end up being a bigger threat than what we're being protected against in the first place....I wish more people realized this.

January 27, 2011 | Unregistered CommenterAnne

Oh Jill, you must be getting more spam...I didn't complete posting my first post.

I was shocked by how many of the hospitals just did not report their elective induction before 39 weeks numbers. While I know it's not scientific to assume those are automatically worse than target, it tends to be the assumption most people make. It definitely makes me wonder how bad it is...and assume it's probably really bad! (Not that that's a fair assumption, but it is the first one I make.)

I was also wondering what "does not apply" means. I get it for the orthopedic hospital, assuming that hospital is specialized in only that area and doesn't do births. But many more than expected have that desgination, and I generally assume that most hospitals do births, at least on occasion. Can anyone explain that designation to me, other than for specialty hospitals?

January 27, 2011 | Unregistered CommenterAnne

Anne,

Reporting is voluntary... Set Measure ID: PC-01, Performance Measure Name: Elective Delivery (Joint Commission)

Probably not a fair assumption but I think it's a pretty common one.

January 27, 2011 | Registered CommenterJill

can i just vent? my sister in law in being induced right now. she is 38 weeks and the excuse is that her baby looks big. ultrasound is guesstamating baby at 8 pounds. my SIL is not big but she's not small ether. She is planing on getting the epidural right off the bat so as not to experience a single contraction. I realize everyone has their own birth pictures i'm just afraid that this early induction is incredibly irresponsible on the doctors part. there is no other excuse for induction besides baby's size which a)isn't THAT big and b) is often inaccurate. end vent.

January 27, 2011 | Unregistered Commenteratara

I always consult Dr. Google when something comes up. Sometimes self-help is the best and most reliable form of treatment available.

January 27, 2011 | Unregistered CommenterDana

atara, how is everyone? Did everything go okay? I hope so.

January 28, 2011 | Registered CommenterJill

Dana, newer patient advocacy literature focuses heavily on using the internet wisely. Elizabeth Cohen's book has a whole chapter on it. She quotes the AMA president in 2001 in his passage:

The nation's top doctors' group advised us to do one more thing to stay healthy. "Trust your physician, not a chat room," they said. People who go online, the AMA warned, "may be putting their lives at risk."

Apparently, the Internet is a scary place for America's doctors.

January 28, 2011 | Registered CommenterJill
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