Thoughts on obstetrics vs family practice

photo by Orcoo

Rixa at Stand and Deliver has a really fascinating post about "Litigation and the obstetrics mindset." She states, "I am trying very hard to understand the obstetric mindset when it comes to risk, malpractice, and litigation in relation to choices such as VBAC or home birth." She presents a very thorough perspective on those issues, including quotes from discussions on obstetrical and midwifery message boards from those two specialties. The most intriguing part to me, however, comes about halfway through the post when she shares the perspective of a friend who is a family practice doctor. Here's what the FP doctor says. It's long, but it's all worth reading:

OB, as a surgical specialty, has a much different "flavor" than the FP [family practice] world I trained in. OBs are surgeons, and many have an "I can fix that!" kind of personality, where issues are seen as black and white, and they rely heavily on their judgment and skills and quick decision making. Surgical training is much more hierarchical than generalist training, and I think that builds in much more of the power issues that we see in medicine so much. OBs primarily view their clients as patients, and their decisions as scientific and don't concern themselves with the softer, social/emotional issues. Because of the power play issues and the idea that the OB is the knowledgeable important person in the relationship, I think this leads to a lot more worry on their part of the consequences of their decisions. The average OB is trained and socialized to be the decision maker and leader in the doctor-patient relationship, and to bear the responsibility for the outcome. They are also socialized to be very risk aversive - but only the risks that impact them the most. There is this overriding cultural expectation that OBs are expected to produce a perfect baby every time - but in reality, I think OBs propagate this much more than their clients do. I think so much could change if OBs (and many other kinds of doctors) could let go of the power differential and allow themselves to be seen as human.

As a family doc, even though I trained in a highly traditional medical setting, I was still trained by family docs, with a strong flavor of know-the-evidence, partner-with-your-patients type style. I think midwives, of course, lean even farther into the psychosocial part of their relationship with clients in their training. I think the more partnership or service style of practice leads to less fear that you will be held solely responsible for your decisions. Our generalist training, and in midwives' case, their woman-centered training, shifts more responsibility onto clients themselves, and I think leaves us feeling less worried about litigation, and more worried about quality care.

Of course these are big generalizations, and there are exceptions to everything, but in general the culture of the surgical specialty of OB is just so different than the culture of midwives, or even family docs.

I don't worry about getting sued very much. It rarely enters my mind as a factor in decision making. I worry a lot more about educating, and about encouraging my clients to make their own decisions. I worry about forming good relationships, providing room for disappointment to be expressed when things don't go the way we hoped, and making our decision making processes completely transparent and understandable to my clients. I worry about making sure my clients understand that there is a lot of uncertainty sometimes in what we do, that no outcome is guaranteed, and that I strive for excellence and hope for luck along the way, too. I hope that the relationships I form with my clients will mean that they can tell the difference between malpractice, and an honest human being doing their best.

Part of the lawsuit crazy fear really does seem incomprehensible to me, though. When I was pregnant with my fourth child, I went to a friend (or more acquaintance) who is an OB for prenatal care, and we had the weirdest argument over me being tested for gonorrhea and chlamydia in early pregnancy. I didn't want to be tested because I have zero risk, and it costs money. She kept saying that it was important to be tested, regardless of risk, because of "medical legal reasons." We went around and around until I finally said: "Look, 'medical legal reasons' only come into play if I sue you, and I can assure and guarantee you right now that I'm never going to sue you for not testing me for gonorrhea and chlamydia. I understand the risks and benefits of being tested, and I refuse. Period." She was terribly flustered that I'd brought up the word "sue" and terribly flustered that I said "refuse" and was clearly uncomfortable and it was so strange to me. In my practice, I matter-of-factly explain the benefits of being tested, and if clients choose not to be, I feel quite content that even if they are making the wrong decision, it's their decision and their consequences so I don't have to be personally invested in it - while she clearly couldn't let go of the idea that by not following the "standard of care" I could somehow accuse her of malpractice later. I still can't understand why so many OBs are so terrified of being held responsible for outcomes they can't control - why are they so frightened of allowing the decision making to rest with the folks who have to live with their decisions!?

This absolutely, 100% squares up with what I have observed from working with obstetricians on the one hand, and receiving my care from family practice doctors, midwives, and nurse practitioners on the other. In particular, we take Eden to a family practice group that I just absolutely love. I think Matt probably finds my swooning devotion a little bit odd, but when you've spent several years contending with just how excruciatingly difficult doctors can be, it feels so incredibly good to have your worries and low expectations blown out of the water by doctors and nurse practitioners who truly care and want to help you. Because that attitude is, I'm just going to say it out loud here, incredibly rare--I thought in medicine at all, but apparently mainly just in obstetrics.

An example: shortly before Eden's 1-month checkup, I found out I'd need a doctor's note clearing me to go back to work since I'd technically been on medical leave. Since schlepping a newborn baby to an appointment for me, and paying to have somebody say "yes, you're fine" didn't sound that appealing, I figured I had nothing to lose by asking the nurse practitioner at Eden's visit if she'd mind jotting a note for me. We were there anyway, right? I was prepared for her to say no, and imagining a response like "Do you know what kind of liability it is for me to write a note saying you're healthy, I don't know whether you're really healthy, and even if you're healthy today, how do I know whether you'll still be healthy when you go back to work," etc etc. Because that is really the kind of logic I see employed on a daily basis. Kind of along the lines of the above--"Even though you know you don't have gonorrhea, and you aren't going to sue me, we need to test you for gonorrhea in case you sue me. For not testing you for gonorrhea. When you refused to have it done." HUH?!

Instead? "Oh, absolutely! I'd love to. That's no problem at all!" The same kind thing when there was some confusion with the front desk as to whether our visit could be billed as a well-baby exam when it was technically just a weight check (meaning a difference of whether our visit was covered at 100% or we had to pay a $20-30 copay)--while many providers play (or are) dumb to the workings of their own offices, let alone the insurance companies, the NP stepped out, talked to them herself, and came back and said "It's straightened out now. There's no reason you should have to pay extra when she's here, she's a month old, and she's had her well baby visit!" Granted, that was the nurse practitioner, but we have found our family practice doctor to be just as delightful. Documentation for Eden's birth certificate? Happy to help. Want to delay vaccination? That's certainly your choice.

I'd wondered about this discrepancy between disciplines and I think the above sums it up very well: OBs are taught to worry about themselves, and family practice doctors (along with midwives and nurse practitioners) are taught to worry about their patients. As pointed out above, there are exceptions on both sides of this, but overall, it leaves you feeling somewhat sorry for obstetricians--but even sorrier for their patients.