Interesting stuff on defensive medicine and c/s rates

iris427 · January 2011

The Unnecesarean just did a series of posts about defensive medicine, how it affects c/s and VBAC rates and how to advocate for yourself. It's an interesting read.

Here is a link to all the posts:

https://www.theunnecesarean.com/blog/2011/1/10/defending-ourselves-against-defensive-medicine.html

ETA There is an intro post and then links to all the other posts in the series at the end. There are some really good ones written by OBs, and it's great to hear their perspective.

Geekchick921 · January 2011

I am of two minds about this, because I'm sure part of the reason my doctor pushed my C-section was defensive medicine, but as a future doctor (likely a future Ob/Gyn) I kinda hate the tone of that article.

Defensive medicine sucks and I absolutely think I was C-sectioned because of it, but I feel like we already knew that it isn't helping the number of lawsuits. It's not the doctors' fault that the system is broken, though, and I don't think the majority of them are happy about feeling like they "have" to push interventions and C-sections to avoid being sued. Ob/Gyns have the second highest malpractice rates after neurosurgeons (and are certainly not paid anywhere near what neurosurgeons are), and can be sued until a baby they delivered is 18 years old.

As part of my job, I have seen the claims history reports for the doctors at my hospital. The Ob/Gyn's folders are several times the size of any other specialty's, and the number of claims involving things like "delay of" or "failure to perform timely" C-section is staggering. I've seen the file for the doctor that delivered Sarah, and it's been a lot harder to be angry at him. At least 15 maternity wards in my area have closed in the last 10 or 15 years because of the malpractice rates for Ob/Gyns being what they are. It's a clusterf*ck and it's not fair for either side.

IMO, the ire should really be directed towards the malpractice climate that makes it so "easy" to sue for delay of C-section and any other suggested negligence. Like Dr. Waldman is quoted in the article, I have never heard of a malpractice claim for "unnecessary C-section". In reality, most malpractice lawsuits never go to court; the malpractice insurance companies just settle to avoid the time and expense of a trial, even though the court would usually rule in favor of the physicians.

I absolutely agree with one part of the article, though. The best way for a doctor to avoid being sued is to have an open, trusting relationship with their patient, in which the patient feels like they understood their issues and treatment options and had a part in making decisions about them. Patients that feel as though their doctors are making their healthcare decisions based on defensive medicine obviously don't have a trusting relationship with their doctor, so no wonder it's not helping the number of lawsuits, right? Go figure.

lilbit923 · January 2011

Wow. I have to say that being knowledgeable about what's out there helped me with my OB. When I first told her that I wanted to VBAC this time she stated the obvious "You've had 2 c-sections. We don' VBAC those moms." So I told her the ACOG has studies on VBA2C, VBA3C, VBA4C and edven VBA5C so I'm not buying it isn't done. There have even been women VBAC with babies at 14-15 months pp like yours truly.

It's like anything they do they are just itching to run you to the OR. I will be asking at my growth scan what the thickness of my scar is and if there are any uterine windows detected. I expect to hear the same crap I did weeks ago about how the machine magically can't tell me that information anymore. Riiight. I'll wait right here till you call the OB in and she can read the monitor for you.

I'm not saying I'll be a success at it. But I do feel much better about me for having read up on what I am allowed to do, what other women have done and how your CAN actually decline options the OB brings up.

iris427 · January 2011

Geekchick921:
I am of two minds about this, because I'm sure part of the reason my doctor pushed my C-section was defensive medicine, but as a future doctor (likely a future Ob/Gyn) I kinda hate the tone of that article.
Defensive medicine sucks and I absolutely think I was C-sectioned because of it, but I feel like we already knew that it isn't helping the number of lawsuits. It's not the doctors' fault that the system is broken, though, and I don't think the majority of them are happy about feeling like they "have" to push interventions and C-sections to avoid being sued. Ob/Gyns have the second highest malpractice rates after neurosurgeons (and are certainly not paid anywhere near what neurosurgeons are), and can be sued until a baby they delivered is 18 years old.
As part of my job, I have seen the claims history reports for the doctors at my hospital. The Ob/Gyn's folders are several times the size of any other specialty's, and the number of claims involving things like "delay of" or "failure to perform timely" C-section is staggering. I've seen the file for the doctor that delivered Sarah, and it's been a lot harder to be angry at him. At least 15 maternity wards in my area have closed in the last 10 or 15 years because of the malpractice rates for Ob/Gyns being what they are. It's a clusterf*ck and it's not fair for either side.
IMO, the ire should really be directed towards the malpractice climate that makes it so "easy" to sue for delay of C-section and any other suggested negligence. Like Dr. Waldman is quoted in the article, I have never heard of a malpractice claim for "unnecessary C-section". In reality, most malpractice lawsuits never go to court; the malpractice insurance companies just settle to avoid the time and expense of a trial, even though the court would usually rule in favor of the physicians.
I absolutely agree with one part of the article, though. The best way for a doctor to avoid being sued is to have an open, trusting relationship with their patient, in which the patient feels like they understood their issues and treatment options and had a part in making decisions about them. Patients that feel as though their doctors are making their healthcare decisions based on defensive medicine obviously don't have a trusting relationship with their doctor, so no wonder it's not helping the number of lawsuits, right? Go figure.

Are you talking about the intro article? At the bottom there are links to the rest of the articles in the series--several are written by OBs and they are very interesting and not anti-OB.

I agree with you that something absolutely needs to be done about the malpractice climate. Unfortunately, I'm pretty sure that some possible solutions to this would be politically impossible in a country where even the relatively small healthcare reform just passed is hugely controversial. For example, I read an article about a hospital in New Mexico that is covered by the federal government instead of private malpractice insurance, so they are able to do way more VBACs and maintain a low cesarean rate without worrying about a lawsuit bankrupting them or messing with their insurance policy. But that would never happen on a national level, at least not in this day and age. I need to learn more about tort reform before I can have an intelligent opinion on it so I'll just leave that topic alone for now.

Geekchick921 · January 2011

iris427:

Are you talking about the intro article? At the bottom there are links to the rest of the articles in the series--several are written by OBs and they are very interesting and not anti-OB.

Yeah... I actually didn't scroll past the end of it. I was already kind of mad. *blush*

I agree with you that something absolutely needs to be done about the malpractice climate. Unfortunately, I'm pretty sure that some possible solutions to this would be politically impossible in a country where even the relatively small healthcare reform just passed is hugely controversial. For example, I read an article about a hospital in New Mexico that is covered by the federal government instead of private malpractice insurance, so they are able to do way more VBACs and maintain a low cesarean rate without worrying about a lawsuit bankrupting them or messing with their insurance policy. But that would never happen on a national level, at least not in this day and age. I need to learn more about tort reform before I can have an intelligent opinion on it so I'll just leave that topic alone for now.

Yeah, I know; it needs an overhaul on such a massive level I can't see it ever really happening. I just didn't like that I felt like physicians are being villified in that intro article. I feel like there are other changes that can happen that will help though. As far as the C-section rate and VBACs go, I think the ACOG changing their guidelines is a huge step (now it just has to get its members to adopt them). The laborist model is going to help a lot as well, in regards to obstetrics malpractice as well as lowering C-section and raising VBAC rates. They have been shown to do that for hospitals that have started using them... hopefully more continue to do so.

Geekchick921 · January 2011

I'm not feeling reading all of these other posts right now, but I definitely want to comment on two.

"Hanging Up My Gloves" makes me really sad. I'm scared I'm going to have any enjoyment I see myself having in delivering babies sucked out of me because of stuff like this. And I see descriptions for cases like this a lot in the NPDB (the Data Bank he mentions). Patient has been disregarding the physicians advice, not following along with standard prenatal care, refusing treatments the doctor recommends, then something goes wrong, they sue and the malpractice company settles. This makes me stabby.

And I cannot stress how much I agree with everything in "Building Trust in a Defensive Environment." I love it.

MAprincess · January 2011

I agree that the malpractice lawsuits are insane. I didn't realize that you had 18 years to sue, really??? I do feel that the original doctors that I interviewed basically told me that I'd end up with a repeat CS and I definitely feel like it was to cover their butts in regards to lawsuits (and I see their side since it is done so often), so the issue is making it so lawsuits can only come up when reasonable. I live in an area where 10 or so maternity wards have closed also.

I ended up going with a midwife who I definitely trusted. At any point, had she said that I needed a CS, I would have trusted her judgement and gone with it. I knew she would only choose that option when truly medically necessary.

cg0112358 · January 2011

Geekchick921:
IMO, the ire should really be directed towards the malpractice climate that makes it so "easy" to sue for delay of C-section and any other suggested negligence. Like Dr. Waldman is quoted in the article, I have never heard of a malpractice claim for "unnecessary C-section". In reality, most malpractice lawsuits never go to court; the malpractice insurance companies just settle to avoid the time and expense of a trial, even though the court would usually rule in favor of the physicians.

I'm wondering what would qualify for you to sue for an unnecessary c/s. My OB was quite careless and, although I might have had to have a c/s anyway, his actions forced it. Basically he talked me into inducing at 39w1d by breaking my water b/c I was showing signs of become pre-eclamptic. He failed to confirm DS's position and broke my water when DS was breech. If we'd known that earlier we could have attempted a version to turn him. I know versions are only 50% successful, but that is a 50% chance that I wouldn't have had to have major surgery.

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