Thursday, March 11, 2010

Dropping In and Frustration

Since my move from Whooville to Newville, I've had to make some adjustments to the new patient population. Perhaps the most frustrating of all, however, are the "drop-in" patients on Labor and Delivery. My previous hospital was a rural, community hospital. It was certainly off the beaten track, and the building? Was old. Really old. The L & D suites were certainly sufficient and functional, but luxurious? Not so much. You had to know where you were going to find the hospital, and it was quite the rare occasion to have patients just "drop-in" for care.

Not so for the new digs. This hospital is new. Pretty much Brand Spanking New, and posh, and beautiful, and, oh yes, right off of a major highway, visible for all the world to see. Which makes for the fascinating phenomenon that is the OB "drop-in" patient. "Drop-in" patients come to this hospital "because it is close," or "because it is nice," or "because it was on the way." So, what is so bad about working in a hospital in which everyone wants to deliver? Well, what is so frustrating is the women who *know* that they want to deliver at our hospital, but do not seek pre-natal care from physicians that cover our hospital. Therefore, any pre-natal labs or records, or history of complications are virtually inaccessible at the time that they come in for delivery. Often patients from the large, downtown academic center (who don't have insurance or have insurance not accepted by our practice) receive all of their pre-natal care "for free" at the downtown center clinics and the purposefully come to our hospital to deliver. The patients are often not troubled by this, and often seem mildly surprised that we "aren't all the same" and have no way to access their records. After all, they are getting exactly what they want. It is much harder for us, as physicians, however, to help these patients. Especially when it comes to their expectations for delivery. It is difficult to develop a proper rapport in the few hours that we have with them. I think that trust is so important in the delivery room.

Even more difficult are the transient patients who stop in on their way through town, like one patient who had absolutely no pre-natal care, and was on her way to deliver her baby somewhere "non-medical" when her water broke, and she decided to stop-in at our hospital. She had, indeed, broken her water, but she refused an ultrasound to assist with proper fetal dating because she was concerned that the "x-ray waves" would damage the baby. She then proceeded to refuse any medical assistance from the hospital at all for over 24 hours, tying the medical staff's hands, and putting them at risk for liability at the same time. Eventually, she agreed to augmentation of labor, and even requested epidural analgesia after a prolonged labor. With medical assistance, she eventually was able to deliver, but the baby boy had definite signs of septicemia (likely due to prolonged rupture of membranes) and ended up in the NICU for over a week. When all was said and done, the mother, upon release from the hospital, said that she and her infant would never step foot in another hospital again, despite the fact that it was with the hospital's help that her child was born and made well when he was sick. To this day I will never understand why she "stepped foot" in the hospital from the start, if she did not want any intervention that the hospital could offer. This case brought a lot of issues that plague the medical profession in this day and age to the forefront.

Thankfully, her baby, despite some health issues at birth (that likely could have been avoided with faster intervention) did well...but what if he did not do well? What if the infant did not survive? Then who is at fault? The hospital? The physician? The mother? These are the questions the haunt physicians' sleep at night. Obstetrical interventions are not only done to avoid lawsuits, they are done to protect the safety and health of both the mother and her baby. However, one bad outcome, one wrong decision, can result in catastrophic professional, financial, and personal losses for the physician. Is it any wonder that we are hyper-vigilant? Is it any wonder that we would jump at any opportunity to prevent a bad fetal outcome, even it it means surgical intervention risks for the mother? It is thanks to Jon Edwards and others like him that the cesarean rates are rising, VBACs are being refused, that patients are being over-monitored, and that interventions are becoming the exception rather than the rule. Without tort reform, without the ability of the physician to operate from another position than that of fear of a poor outcome, then I am afraid that obstetrical care will remain the same in this country for years to come. Please consider that your rage just may be misdirected.


C said...

We have a HUGE "walk-in" population where I work (Large Urban Area, very low socioeconomic status population), and it's a massive problem. I'm actually doing some research on this, on the idea that if I can prove that their outcomes are worse and their costs are higher, we can start to address the problem. Here are some of my rough thoughts on the subject:

But I think the provider frustration is the biggest problem with this, and that's hard to measure.

Anonymous said...

Just wondering...

Who is "Please consider that your rage just may be misdirected." directed towards?

Rebecca said...

I was going to say some things about this, and then I read gravity circus' blogpost and it said a lot of what I was thinking!

But I will add:
Getting all economics "people behave rationally" on this: like you said, your drop-in patients are getting closer to what they want (although probably not "exactly", they would likely also prefer to get PNC and delivery services from you, but like you said the insurance is an issue.) I agree that trust is hugely important in the delivery room, but keep in mind that at the big academic center they probably won't ever have met the OB who delivers them either. Why not go to the nicer place? So this practice makes perfect sense to them. They really have no idea that there's no way to access their records. They don't realize that the records are important. It's just not on their radar: frustrating, but still true.

With that in mind, I wonder if there's something that can be done (possibly along the line's of gravity circus' project?) to mitigate some of those issues: access to PNC records from the downtown clinics (although I can see that might be very tough both logistically and politically), education for the patients at those clinics, or (this would probably be out of your scope, but this is my public health thinking) improving the continuity of care and relationships at the downtown clinics so that women are motivated to stick with their care providers.

Anonymous said...

Dr. Whoo-

I am curious to hear your thoughts on tort reform and what specific reforms you think would be helpful. (I say this in all sincerity).
Attorneys do not decide how much a jury awards. If a jury hears a case, somehow determines that the physician, hospital, etc., did not meet an acceptable standard of care and bears liability, then it is up to the jury how much to award or not award. It is just a pet peeve of mine when people have a picture that the lawyer is sitting there waiting for the verdict ready to fill in whatever amount their heart desires.
I think there are many more reasons that the C-section rate is rising besides too many medical malpractice attorneys running around.
On a different note, the Newville Hospital sounds fab!
-Amy in OH

Anonymous said...

I hear you about the frustration of dealing with L&D drop in patients. Where I practice, many of our drop ins are illegal immigrants from Mexico that come across the border to have their baby in the our nice new L&D. At least they are grateful for the care they receive and don't have many inappropriate requests or complaints.

dr. whoo? said...

C~ Your research project sounds awesome! And, yes, physician frustration is difficult to objectively quantify. If you have access to poll the physicians involved, perhaps a query on "how frustrated are you" scaled 1 to 5 and quantify it that way.

Anon~ It is not just the physicians driving a highly interventive labor and delivery, it is the legal environment, JACHO standards, and hospitals doing more and more to cover themselves against hefty liability suits. Even if physicians are operating within the "standard of care." As the natural birthing community is fond of saying, "Sometimes babies just die." In the hospital system, that statement is followed by, "...and someone is at fault."

Rebecca ~ The thing is, though our practice does not accept a few select insurances, there are several other practices delivering in our hospital that *do* accept these insurances. And none of the practices deny someone who is "self pay." I definitely believe this is not on the patient's radar, so to speak, but it makes it harder as a physician to care for them. EMR has the potential to mitigate the dissemination of important information, but is far away as a presently viable solution. As for the academic center, most see the residents rotating through the clinic, so they have likely met the physician that will ultimately deliver them. I cannot speak to what kind of education they receieve while there, but from what I routinely hear, they mostly avoid the hospital because it is "old" or "not as nice" more than anything else.

Hi Amy~ I thought I may hear from you on this post! I always value your comments, and of course I don't envision all lawyers sitting around filling in zeros behind an arbitrary amount. (But they do put out pretty snazzy commercials for consultation to "see if you are entitled to compensation.") ;)

The juries (lay people) usually do the rewarding because they see a family that lost a child, or with a damaged child, and immediately, emotionally (not often rationally) decide that the big, bad, mean, knife-sharpening (or, in most cases, didn't sharpen the knife quickly enough) Porsche-driving (HA!) doctors deserve to have it stuck to them, whether the standard of care was breached or not.

Continuous EFM can leave way too much to interpretation, and you give 10 different OBs the same strip and some will see ominous signs where others will not, and hindsight is 20/20, and sometimes it is far more lucrative (and less malpractice insurance) to be a "professional witness." Texas has done a nice job with tort reform, and Florida also has an interesting set up with NICA. Of course malpractice insurers put physicians and hospitals under extreme pressure to not provide VBAC services, as well, driving up the repeat Cesarean section rate and driving VBAC numbers way down. Lawsuits made forceps deliveries nearly obsolete, and the vacuum may not be far behind. There are even actions against physicians who are though to have "too many" third and fourth degree vaginal lacerations. The cold fact remains, as long as a damaged baby is a "golden ticket," physicians will be under more and more pressure to perform seemingly "unecessary" interventions.

Trope said...

I'm from Chicago, and work with teen moms, who will freely disclose that they plan to drop in to their neighborhood hospital for the birth because their "medical home" is two trains and a bus away, and they won't take that trip during labor. Argh. The best I can tell them is to bring their records.

Though it translates as rage, I think that most people are just constantly surprised that birth is an unpredictable, sometimes scary thing. We just can't deal with that fact. For my son, I had an unmedicated birth where I walked (umm, staggered) into the hospital thirty minutes before the birth, no fuss, and left me with a whole, "What do you doctors know anyway?" attitude. I had the privilege of being with my best friend when she delivered her second child, and it was quite a bit more complicated and left me deathly afraid of ever giving birth again. I think it's far easier for people to think that with "problem" births SOMEONE must have done something wrong, rather than facing up to the fact that those of us who had "easy" births are just astonishingly lucky.

April said...

When I got out of school, I never realized that the world of mommies and babies and birth (i'm on the baby-end, in NICU) would be so different from the warm cuddly happy place I expected it to be. Boy, I was wrong. I feel your pain...

shruley said...

I really like your blog, although I fear I may be one of those "natural birth people" you refer to. Just last week someone approached me about helping get tort reform passed in our state, as that is the cause that our state's "better birth colation" will be targeting next year. The ACOG is saying liability is a huge factor is offering VBAC, so that's the problem we're addressing and focusing on. Although it may not seem like it, we (or at least some of us) do understand that OBs aren't operating in a bubble. I was heartbroken to see my former OB lose a lawsuit she never should have lost. It was insane, she followed the standard of care and did nothing wrong, yet the baby had some injury from shoulder dyscosia. She lost because they said she should've done a c-section because the baby *may* have weighed 9 lbs. from a late ultrasound. Can I really blame her for doing a c-section the next time she has a suspected large baby, even though the weight doesn't really predict or cause shoulder dyscosia? It's a crazy world we live in, and there are no easy fixes.

Anonymous said...

And is there also a sign on the hospital door that says "lunatics welcome here?"
That being said, you can bet your bippy that malpractice attorneys (and crazy juries) have a LOT to do with a lot of th interventions that get done. Tort reform is the one thing we haven't heard much about it all this talk of health care reform, and without it there will be no real reform.

Rebecca said...

It seems like an interesting investigation then (still thinking with my public health/research-y mindset) is to delve more deeply into patient's reasons for switching (perhaps there's something deeper than the reasons they're giving, or perhaps not). They may not meet the same residents often enough, or not know the residents will be delivering their babies, or like you said just not care/see the value in continuity of the provider relationship. Maybe there's a perception that nicer = better quality care. Or maybe people just do want a newer, nicer hospital and don't realize that their insurance is accepted there.

In any case, it might be worth some proactive education on the part of the downtown clinics: "Some people change their mind about where they want to have the baby. If you want to deliver at Hospital X, they will take your insurance and this is the information to switch your care to them. If you just show up at Hospital X in labor, they will not have your records and all of the information we have to help take care of you in labor will not be there." Do you know if they do anything like this? Do they mind losing the birth business?

Anonymous said...

Dr. Whoo-
Emotion is definitely a huge factor in juries. Although I definitely understand (and agree with you to a point), I don't think that emotion can or should be completely removed from acts of a jury. Unless you're a robot, emotion is going to come into play.
Ohio has done some interesting things with tort reform. A few years ago, doctors were having a huge problem with malpractice insurance rates to the point that they were closing practices or leaving the state. We now have caps on all the different types of damages (economic, non-economic). The attorney filing a medical malpractice lawsuit is also required to file an affidavit of merit with the case basically stating that the case is meritorious. If an attorney is running around filing frivolous lawsuits, they will face disciplinary action- as well they should.
I think part of the bigger issue gets back to the idealization that most people (myself included at a time) have of pregnancy and childbirth. Bad things do happen sometimes and it is usually not someone's fault. Do not get me started on those commercials that imply otherwise :)
It is nice to have a discussion with someone from the "other" side. I think all of us have a lot at stake in this issue. When good doctors are afraid to practice a certain way for fear of liability, no one wins. When we lose confidence in the legal system, we lose as well.
-Amy in OH

Anonymous said...

Gee, I've never had much confidence in the legal system.

MI Dawn said...

I can recall when a lot of women went to hospital "X" because they had a really nice dinner after you gave birth for the husband and wife. Didn't matter to them if their doctor went there or not. I recall another woman who went to New York to have her baby (bypassing 8 other excellent hospitals) because good doctors only work in NY (although her MD was out of our state).

I think malpractice caps and limits on how long afterwards one can sue would be wonderful. Virginia put one in effect years ago. Seems to be working.

Anonymous said...

I was so disappointed that tort reform was completely missed during all of the talk about healthcare reform. I think that a lot of physicians, and not just OBs, practice in a way to CYA. I see lots of unnecessary CT scans and MRIs ordered because "we better make sure" and all of these unnecessary interventions contribute to cost inflation, increased premiums, and for those on Medicaid, increased costs to the tax payers.

When I worked in NICU, I recall a case where a young woman had routinely missed appointments in her third trimester despite being high risk and having had 3 prior c-sections in relatively quick succession. She was offered transportation to the appointments, called frequently by the office due to their concerns and still never saw a doctor from 35 weeks on. Sadly she finally came to the hospital at 39weeks bleeding with a ruptured uterus. Mom went into DIC and died, baby saved but bad, bad hypoxia and severely brain damaged to the point of needing 24 hr nursing care. Surviving family sued everyone including the doctor, the hospital ER staff where Mom died, and our hospital who had observed her overnight around 33 weeks. Our hospital fought it, but the hospital where Mom died settled because they knew that despite the overwhelming evidence that Mom failed to heed medical advice, they knew that if you put a picture of a young dead mother and a brain damaged baby in front of a jury, there's no telling how they might lean. That type of settlement further encourages lawsuits.

Luckily on the NICU end, our nurses avoided being involved, but it was a sad situation that frustrated all. Just one small example of how in the hospital, it's always someone's fault (and rarely the patient). That type of thinking keeps me from becoming an NP, I don't want any more liability than I already have at the bedside.

Love your blog!

OldGirl said...

I have to agree that dropping into the hospital with the warm and fuzzy ads and billboards and the cushy delivery rooms makes sense from a certain (not yours) perspective.

At my center you alternated between an doctor and an NP in prenatal visits. From day one they told you not to expect to see your doctor at delivery. So already the woman isn't that attached to "a" doctor.

In truth, with my straightforward deliveries the doctor was not spending much time with me anyway. With my last child I heard the nurse tell the doctor - "hey don't wander far, she's going to deliver." If a young woman has friends who've been through this they're most likely pointing the seeming non-importance of the doctor out to her.

Hopefully most of the women who drop-in are young and will have uncomplicated deliveries. You would "think" that someone who'd had a complicated pregnancy would feel apprehension about delivering someplace where they didn't know her story and wouldn't show up un-announced.

We'll see over the next zillion years if the EMR initiative improves this.

Knitted in the Womb said...

Tort reform is SO important. If a patient refuses an intervention after being told the possible negative outcomes, and one of those outcomes occurs, the patient should not then be able to sue saying "the Dr. didn't really make me understand that it could happen to ME." Hogwash.

Likewise, the whole way malpractice court decisions are made needs to be changed. A Dr. at the NIH VBAC suggested that there should be special malpractice courts with Dr's as judges, just as there are special workers comp courts. I'm not sure what the best set up would look like because I want to make sure the "white wall of silence" does not short change true victims of malpractice...but I also want to make sure that malpractice awards aren't a sympathy system. Someone I know sat on the jury for a malpractice case, and the rest of the jury was just captured by the injured baby--cerebral palsy which might not even be caused by a "birth event!" "The parents deserve to be compensated!" they said. "But what did the Dr. do wrong?" she asked. They couldn't point to anything, but "someone needs to pay!" and so the ruling went against the Dr. :-(

Sylvia said...

As my ob husband calls them, "my just show ups"

love your blog

Margaret Polaneczky, MD (aka TBTAM) said...

This post says it all. Patients have expectations out of line with reality, refuse standard of care, then sue if things go wrong. Thankfully for all involved, things went well with this one.

We need tort reform.