I decided to become a doctor because of one basic assumption: it meant helping people every day. And I’m not alone — most physicians consider their profession to be a noble one. The nobility of medicine is reinforced in every aspect of the training doctors go through. We work hard to recognize illness when we see it, and to memorize the right lab tests to order and medications to prescribe to treat those illnesses. We’re told that when we’re done, we’ll be authority figures in our specialties and that our patients will be able to rely on us to guide them and keep them safe.
But what happens when that’s not true? When evidence suggests that the treatments we’ve been proposing and procedures we’ve been performing might actually be doing more harm than good? You would think that physicians would follow the data and immediately change their practice because that’s what’s right for their patients. Unfortunately, we’re not always as noble as we ought to be.
As an obstetrician, I realized my own culpability early one morning, when I was just starting a 24-hour call shift in the hospital. All was quiet on the birth unit. Patients had labored overnight and were snuggled in their beds with their newborns, enjoying that blissful — and temporary — slumber that follows giving your all and getting the ultimate reward in return. But doctors know that just thinking things are quiet, even if no one actually says the word out loud, can be a curse. Sure enough, the phone nestled on my hip started to ring.
It was a local midwife calling, hoping our team could turn her patient’s baby from breech to head-down. She had been planning on a home birth and a breech baby would mean just the opposite: a C-section. I invited them in for the procedure and they arrived an hour later. The midwife had been in practice for many years, and I had grown to respect her judgement when we had collaborated in the past. She embraced me warmly and introduced me to her patient, who was pregnant with her first child and looked as though she was brimming with anticipation. If we were successful, this would bring her one step closer to the birth she had been envisioning.
I got them settled into a hospital room and walked them through what to expect. Turning a baby can feel intense and occasionally painful. Sometimes, no matter how hard we try, we can’t coax the baby to change position at all. Complications like breaking the bag of water early or fetal distress can arise, but they’re rare enough that I’d never actually seen them happen.
Our patient accepted all this with perfect calm, her hands cradling her stomach. She glanced at her midwife, then smiled at me.
“I really think this kiddo wants to turn. It feels like he’s been trying for weeks. He just needs a little help,” she said.
“Exactly. He wants to meet you in the tub at home, not in the operating room,” her midwife chimed in, winking at me. “No offense.”
“None taken,” I laughed. “Water births are lovely.”
I put my hands on her belly and felt that her baby was already on the larger side and was firmly lodged in her pelvis. After a few minutes of effort, I was able to sneak two fingers under him and lift him just enough to get some wiggle room. Our patient gritted her teeth but nodded at me to continue despite her discomfort. With my other hand guiding the baby’s head, I incrementally rotated him clockwise, bit by bit. After only a quarter turn, however, he started to resist me and popped right back to breech position. The second attempt was far easier. I only had to move his head downward several inches before he took over. It was as if he suddenly realized that was where he was supposed to go and swam the rest of the way himself.
“He did it, didn’t he?” our patient gasped, her pain forgotten and her eyes now wide with delight.
“Sure did!”I replied, leaping up to return her high-five, the slap ringing out triumphantly in the room.
“What happens next?” she asked, a grin still spread across her face.
“We’ll put him on the heart monitor to make sure he’s adjusting to his new position, then you can go home and wait for labor,” I explained, wheeling over the monitor and placing it on her abdomen.
As soon as I heard his heartbeat, I knew something was very wrong. It was far too slow — less than half of what it should have been. Thump…thump…thump. A sign of severe distress. Her midwife and I sprang into action, helping her roll to her left side, then onto hands and knees, hoping we could find a position that would be less stressful for her baby. Her nurse simultaneously started an IV fluid bolus.
We all wordlessly concentrated on her baby’s heartbeat as the minutes ticked by, willing it to increase. But it didn’t. It was actually slowing even more. I nodded at her nurse, who pressed the emergency button, alerting the rest of the staff to come assist us.
“As soon as I heard his heartbeat, I knew something was very wrong. It was far too slow — less than half of what it should have been. Thump…thump…thump. A sign of severe distress.”
“I’m so sorry,” I told our patient, who had reached out and grabbed my wrist so tightly it hurt. “None of what we’re doing seems to be making a difference. I’m not sure what’s going on, but I do know your baby is telling us he needs to be born ― right now.”
I silently wondered whether the procedure had caused her placenta to separate from her uterus. Was she bleeding internally? Was her baby deprived of oxygen? I could feel my palms start to sweat.
“So, after all that, I’ll need a C-section anyway?” she started to sob, her previous calmness evaporating, as extra nurses rushed into the room.
“Yes, and we don’t have a moment to waste,” I said, explaining that the choice was hers, but that I didn’t see another safe path forward.
She gave her consent and as I started the surgery, I had to fight to keep the scalpel in my hand steady. Although I perform C-sections frequently, and I’m no stranger to the adrenaline of emergency surgery, it never seems to get easier. Please let this baby be healthy. Please.
He was a little pale when I pulled him out seconds later, but he took one look at me and started to scream, his small fists punching the air. He was tangled in his umbilical cord, but there was no bleeding and everything else looked normal, so it wasn’t clear what had caused his heart rate to drop so dangerously.
After we had finished up in the operating room, and I had updated our patient’s family, I found myself walking to the hospital’s coffee shop with the midwife.
“I feel bad things worked out this way,” I said to her, shaking my head.
“Don’t,” she replied. “You just did your job. In fact, you did exactly what we need obstetricians to do: deal with rare emergencies.”
“Sure, but there’s nothing better than an uncomplicated birth, where everyone sings ‘Happy Birthday’ to the baby and counts fingers and toes, right?” I asked wistfully.
“Of course, but we don’t need doctors for that,” she said, winking at me once more.
Her words stopped me cold. Attending uncomplicated, healthy births was the biggest part of my job and my most favorite, full of so much joy and promise. But that didn’t mean she was wrong.
Later that night, when the unit was again quiet, I thought hard about what she had said. Research shows that healthy patients who have their births with midwives, as opposed to physicians, have better birth outcomes. They have lower rates of C-section, as well as lower rates of episiotomy and a reduced risk of fetal loss before the third trimester. They report better communication with their providers and overall have a higher level of satisfaction with their birth experiences. The majority of births attended by midwives occur in hospitals, with emergency assistance immediately available if needed. Studies haven’t found differences in Apgar scores or admission rates to the NICU between births with midwives and births with doctors. Midwifery care also costs significantly less. And yet, 90% of births in the U.S. are attended by doctors.
Obstetricians are far from alone in failing our patients. Cardiologists continued to perform stenting for patients with a particular type of chest pain, to the tune of 500,000 procedures in the U.S. and Europe each year, despite research completed years prior showing no improvement in risk of heart attack or death, and no improvement in pain compared to less invasive treatment with medication. The same is true for orthopedic surgeons who continued to perform a knee surgery called arthroscopic debridement, even though studies showed the procedure was ineffective.
Unfortunately, there are too many similar examples to list here. In Washington state alone, we know that over 600,000 patients undergo unnecessary treatments of various kinds every year.
The American medical system has a problem, and it’s that we simply aren’t adapting our practice habits fast enough to match what research tells us is best. Physicians tend to cling to outdated treatments and procedures, relying on our own experiences, rather than trusting data. We’ve also gotten used to being paid for those services, which just reinforces bad habits. In obstetrics, doctors intervene in birth too often, in spite of studies telling us to back off. We’re so used to dealing with the rare emergency, like the one I described above, that we see risk even where there isn’t any. As much as I would like to believe I haven’t harmed patients in that manner, years of adrenaline-fueled C-sections probably do cloud my judgement about managing normal birth. And the data backs that up.
Every physician has a responsibility to help change these patterns. I’ve taken this to heart and have stopped attending low-risk births. The future of obstetrics is caring for higher risk pregnancies and dealing with the emergencies we’re so well trained to manage. That’s the best use of our skill set — a skill set honed to recognize and treat illness rather than normal physiologic processes. The cultural change that’s required in obstetrics, just like the cultural changes needed in cardiology and orthopedics, won’t happen instantaneously. But we can take a step in the right direction now by recognizing that we don’t become medical authorities when we finish our training — the pursuit of nobility is a journey that never stops. We must constantly learn and evolve to serve our patients better.
Kate McLean is a board-certified obstetrician-gynecologist in Seattle. She’s working on a memoir about practicing medicine in the U.S. and abroad in Tanzania.
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