July 18, 2012
In Native American culture there is a premise that Nature thrives on order but it is man who creates the disorder. That thought came to mind last month when I presented yet another malpractice case for review with a panel of colleagues. A patient wanted to be induced at 39 weeks and inevitably had significant complications with a poor birth outcome. In my expert opinion, I suggested that the physician should have waited until the patient was 41 weeks before she attempted an induction and one of my colleagues thought that I was vehemently wrong. “She was full-term and entitled to an induction” he practically shouted in my ear. “That’s not the point,” I countered. There was no reason to do the induction except for physician and maternal convenience. I reminded him that most high-risks specialists will start fetal monitoring and nonstress tests (NSTs) at 40 weeks to document fetal well being and then induce labor at 41 weeks if it has not started spontaneously.
At 39 weeks, the cervix is usually thick which means it has to be softened with medication before Pitocin (the medicine that starts contractions) can be given. Anytime an induction goes beyond 48 hours, there is a strong possibility that it will end in a C-section. At 41 weeks, the cervix is usually soft and if an induction must be started, it has a much greater success rate for a vaginal delivery.
Very few physicians will allow a patient to deliver beyond 42 weeks because the baby gets too big and the placenta becomes old. An “old” placenta, aka “grade 3” means the baby could possibly receive inadequate oxygen and inevitably there will be meconium which is an internal bowel movement that sometimes indicates fetal distress.
According to the Bloomberg News, “Aetna has renegotiated maternity payments with 10 hospitals around the country so far, bringing rates for cesareans and vaginal births closer together.” This will inevitably decrease my colleagues’ checking accounts but please do not look for sympathy from me. The standards of medical care were written for a reason. Performing inductions of labor for the sake of “convenience” is certainly not one of them.
March 9, 2011
Did you ever love something or someone so much that you had to walk away because it hurt too much to stay? That’s how I feel about medicine. From the moment I saw my first delivery, I was hooked and there was no turning back. Perhaps I’m highly offended at our present state of affairs because I had to work so hard to gain acceptance into med school. I spent countless nights in the library at Columbia School of Physicians and Surgeons studying for the MCATs. Endured physiology, histology, biochemistry, gross anatomy (included the dreaded head and neck) and microbiology so that I could eventually diagnose clinical problems. I walked through the fire of residency training and came out whole on the other side. Yet, despite all of these humble achievements, I couldn’t see the destruction of healthcare coming. And neither did many of my colleagues. However, instead of banning together to save our profession, some of us allowed ourselves to be fiscally co-opted giving rise to the birth of “volume oriented medicine.”
Healthcare is now a business and quality of patient care has flown out the window. Billable procedures with diagnostic codes are the order of the day. “Productivity” is a buzz word, a euphemism for volume. The insurance companies are paying less, yet the healthcare providers are expected to do more. The number of patients on schedules increases and it has become “normal” for some of my colleagues to see 48 pregnant women in a day. A former medical director decided that he wanted to increase “productivity” even more so he paid physicians on a per-patient-basis and of course, his theory worked. When one of his cronies had 80 pregnant women scheduled in 5 minute intervals for one day, I had seen enough. I wrote a letter of complaint to the Florida Board of Medicine and was informed that there was no law that prohibited the number of patients a healthcare provider could see in a day. I then contacted the American College of Obstetrician-Gynecologists (ACOG) and they too, had no protocol or rule about volume. So, it was the wild, wild, west regarding patient care. No rules. No boundaries. And certainly no patient protection. Regime changes occurred, but the “numbers” game continued. I had had enough. So after 15 years of attempting to administer quality care in the midst of chaos and strife, I have tendered my resignation. There is nothing more that I can do except put it in the hands of God.
June 21, 2010
When you try to do the right thing in medicine, it’s a very lonely walk. I’ve been a physician for over two decades but have yet to develop immunity to hospital politics and corporate agendas. It still hurts beyond measure when my patients encounter discrimination simply because they have Medicaid.
Today’s economy has proven that no one is exempt from losing a job; a home; a spouse or their dignity. If the truth be told, we are all just one paycheck away from getting the dreaded pink slip. Medicaid insurance is the government’s safety net for the working poor and has traditionally been shunned by physicians but now hospitals are following suit.
I remember when the only cancer specialists in a small Louisiana town wouldn’t provide cancer patients with chemotherapy if they had Medicaid so the patients either sought care in another town or died from benign neglect. Perhaps it’s the memory of those cancer patients who were denied access to care that makes me fight so hard for my patients to be delivered at a quality hospital despite the hospital’s alleged resistance. In New York City, it’s a well-known fact that a renowned teaching hospital places Medicaid pregnant patients on separate floors but at least they accept them for obstetrical care.
Complicating my dilemma is another community hospital that has had quality care issues in the past and would “love” to have my patients because their patient census is shrinking. Most of the physicians in the community no longer deliver at their institution opting to take their patients to a new competitor hospital that recently opened its doors for business.
Although I have been involved in a recent arm-wrestling match with powers-that-be to “steer” my patients in a certain direction, I ultimately leave the decision up to the patients regarding their hospital of choice. If a hospital accepts Medicaid insurance, then they have to accept Medicaid patients.
The “heart” of medicine has flat-lined and is in dire need of CPR. STAT!
May 19, 2010
I read yet another medical malpractice case that made me cringe. The baby was dying in plain view as seen on the fetal monitor but no intervened until it was too late. The patient had even requested a C. Section because she was exhausted but was encouraged to continue laboring. She eventually delivered vaginally, but also buried her newborn who suffered severe brain injury.
During the case review, the healthcare provider used the Enron excuse and blamed the nursing staff for the poor outcome, alleging that he was never informed there was a problem with the fetal tracing. He was also responsible for several other deliveries that had occurred during the same night. While that may be true, the patient was still under HIS professional care. Most hospitals have central fetal monitoring systems where the tracing can be visualized in several places including the nurses’ lounge and the providers’ on-call room. I have said this in the past and will continue to emphasize the importance of the fetal heart tracing. It is equally important for your healthcare provider to know exactly what is going on with your labor. So, here are a few tips to improve your chances of delivering a healthy baby:
- Ask whether your provider will be in the hospital while you are in labor. If not, could she or her representative give you and your family an hourly update on the status of your fetal tracing.
- When you are admitted to the labor room, ask how many other patients of your provider are admitted as well. If more than three, ask whether there is someone else that could be consulted regarding such as a hospitalist or your provider’s partner in the event he is busy.
- According to the new standards of fetal monitoring established by the National Institute of Child Health and Development (NICHD), if your fetal tracing isn’t “reassuring,” then someone needs to give you a report about the tracing every 15 minutes. If the tracing suggests repeated problems then your baby needs to be delivered as soon as possible.
Please be empowered. Please be pro-active. A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
May 12, 2010
If it appears that the number of ob-gyn physicians in private practice is shrinking, it’s not a figment of your imagination; it’s real. There are a burgeoning number of obstetricians who can no longer pay for malpractice insurance but they’re too embarrassed to tell you. Shrinking reimbursements (or payments) from insurance companies coupled with higher medical practice premiums have changed the landscape of obstetrics dramatically.
Some Ob physicians have stopped delivering babies, others have retired from private practice and many have become hospital employees called hospitalists. Hospitalists will take care of you in the hospital while your ob provider sees patients in the office; in some cases, a LOT more patients, but more on that in a minute.
Contrary to popular belief, the days of milk and honey for most physicians are gone. Money previously spent on vacation homes, boats, luxury cars and exotic vacations is now used to pay for billing code specialists, and triple the number of their original office staff in order to fulfill insurance demands. False denials of payments by insurance companies mean additional paperwork and manpower. Delay of payments is the order of the day and higher patient co-pays certainly don’t help. Many physicians can’t provide health insurance for their office staff because of prohibitive costs.
It’s not a coincidence that gyn-“spas” are on the rise and your gynecologist is now doing liposuction, facials and selling vitamins. Some obstetricians opt to see more patients as a way to compensate for their losses and that becomes a dilemma. As the number of patients increases, the quality of their care decreases.
There is also the danger of monopolies forming when hospital systems purchase physician practices which could drive up the cost of healthcare even more and limit your physician’s autonomy. So, what is a patient to do? Empower yourself with information. Ask how many patients your physician sees per day before making an appointment. If your insurance company is delaying payment for your procedure, file an official complaint with your State Commissioner of Insurance or to the Center for Medicare and Medicaid if it’s a self-insured plan. If your OB is honest enough to admit their concerns, ask how you can help.
Small changes CAN make big differences.
April 19, 2010
Anything that improves the quality of life deserves recognition and praise. I was impartial to the use of cord blood until I read about the case of Chloe Levine (see Growing Use of Newborn Umbilical Cord Blood in Regenerative Medicine)
Chloe Levine was born with the left side of her brain not fully developed and it contained fluid. Her parents noticed that she was unable to hold her bottle at nine months old and subsequently learned that she had developed cerebral palsy. Of course, they were devastated. As obstetricians, it is our goal to help a mother have a healthy baby and when that goal is not achieved, the anguish and despair is palpable.
Chloe’s parents had stored her umbilical cord blood and when they heard about an experimental procedure that used cord blood to reduce the effects of cerebral palsy at Duke University, they decided to give it a try. Chloe began treatment on May 27, 2008 and improvement was noticed a short time later. The stiffness of her right side was gone. She no longer needs physical or speech therapy and when she began preschool, she did not qualify for special needs services. What an amazing story.
There are more than 100,000 cord blood units currently stored in banks worldwide and fall into three categories. Public cord blood banks are usually non-profit. They collect and store cord blood units for anyone who has a medical indication for a stem cell transplant. Private cord blood banks are for-profit entities that collect and store cord blood for families who can pay for such a service. The cost for this service varies from $1100 to $1750 for processing the initial specimen and then there is an annual storage fee of $115 to $125 for each unit. Directed cord blood banking is a service for families who has a relative with a need for a transplant and who is also expecting a child. The collection and storage of the blood are free for families who have a medical need.
Although umbilical cord blood is considered investigational, it is certainly worth considering especially if you have a family member who can benefit from a transplant. Additional information may be obtained from the National Marrow Program’s website at www.marrow.org or the Children’t Hospital Oakland Research Institute www.chori.org/Services/Sibling Donor Cord Blood Program/indexcord.html
I am extremely happy for the parents of Chloe Levine and hope there will be more success stories such as hers in the future.
*Full disclosure: Dr. Linda Burke-Galloway has not received financial support from any cord blood bank nor does she have any financial interest or associations in such companies.
March 22, 2010
The Basil and Spice article, Doctors Will Quit Under New Healthcare Proposals really touched a raw nerve. The author, Dr. Jeffrey English, an Atlanta neurologist proposed that physicians will “quit” because of government healthcare involvement. Dr. English, with all due respect, please speak for yourself.
The time for physicians to “quit” was when the insurance industry took over our profession. They introduced managed care, bribed our colleagues with “capitation” income and then entered the back door of our profession and like a thief in the night, took over. We, as physicians are to blame for this unholy mess. We never stood up to the insurers for fear of being “disenrolled” from their lousy plans. We never protested for fear of being deemed as “antitrust.” We never complained when they redefined us as “providers.” And sadly, many of us never fought for our patients’ rights or dignity for fear of making waves.
The nonsense of “government” takeover is a joke! The “government” wouldn’t have to intervene if we had stood our ground, but we didn’t. We now have to depend on the government to make the insurance companies pry their greedy hands off our profession and patients. I’m an Ivy League grad (Columbia U.) and a board certified ob-gyn physician. I’ve devoted my life to serving vulnerable, public health patients, the kind none of my colleagues want to manage. I live next door to a teacher, a bank manager and live within my means. My kids attend public school. I’ve been taking care of Medicaid patients all my life and I’m not starving, still breathing and living in a country that allows me to be free. Doctors will quit? Really? I think it’s much too late for that now. We, as physicians need to put our egos in our pockets, roll up our sleeves and find some solutions instead of whining like babies.
March 20, 2010
The Russians have a saying: “One who sits between two chairs may easily fall down.” Representative Kosmas, as a constituent in your 24th Congressional District and as a public health physician, thank you for having the courage to vote for healthcare reform. I know this was a difficult journey and that your professional career is on the line. However by voting for healthcare reform, you will be remembered in history as a pioneer who gave the American people a beacon of light and returned the “care” back in healthcare.
The healthcare bill is not perfect, I actually cried when I first read it. As a physician, I have witnessed the devastation that insurance dynasties have created by placing profit before people and billing codes before treatment. They thought they could marginalize physicians and nurses by referring to us as “providers.” They ignored our years of expertise and training. They annihilated the profession of medicine.
I know that the pharmaceutical and insurance lobbyists were bombarding you with temptation that would have been easy to deposit into the bank of future favors. However as a very wise man once said “What good does it profit a person to gain the whole world but forfeit his soul?”
Tomorrow, you will cast your vote and change the course of history. You have pushed through your fears and stepped into greatness. As your constituent, please rest assured that I will have your back. You have earned both my trust and my vote in the next election. I will knock on doors for you. I will volunteer for you. I will be there for you in your time of celebration but also in your time of need. You are now the crown jewel of my congressional district. May God continue to bless you.
March 15, 2010
A blue-ribbon panel of physicians, midwives and other healthcare providers convened at the National Institute of Health to discuss the dilemma of vaginal birth after cesarean (VBAC). At the end of the three-day-conference, they issued a statement that read: “Given the available evidence, TOL (trial of labor) is a reasonable option for many pregnant women with a prior low transverse uterine incision.” Most obstetricians know that, however convincing the hospitals is another matter.
The vacillation of VBAC policies makes me dizzy. In the late eighties and early nineties there was a tremendous effort to promote VBACs and dispel the myth of “once a cesarean section, always a cesarean section.” I recall the days of my residency training when we would call hospitals in foreign countries in an attempt to document a uterine incision of a pregnant patient who had one previous cesarean section and had presented to our hospital in labor. To section or not to section, was the issue at hand. If a woman had a vertical uterine incision, then she must have a repeat cesarean section to avoid the possibility of rupturing the uterus. However, is she had a low transverse or horizontal incision, than ideally, she was a VBAC candidate, barring any other issues such as more than two cesarean sections, fibroid surgery (aka myomectomy) and other uterine procedures that are too complicated to mention.
I blissfully remember taking care of a patient with two previous c. sections who presented in labor at 8 centimeters. She ultimately had a successful VBAC and I was greatly relieved. I dreaded doing repeat c. sections. Fighting layers of scar tissue (adhesions) from previous surgery is not a pretty sight when you’re attempting to reach the uterus and deliver a healthy baby.
Today, most hospitals will not allow VBACs unless the physician remains in the hospital during the patient’s entire course of labor. Since most physicians refuse to do so, a patient is forced to have a repeat c. section. When you deny a woman’s freedom of choice, please be prepared for the consequences. VBAC activism is on the rise and I hope it continues to spread.
March 8, 2010
Kudos to CNN reporter Elizabeth Cohen for reporting on hospital waste; the “open” secret has now been revealed. See Healthcare Industry Sick With Medical Waste. Physicians and nurses have known about inflated hospital charges for years and now the public does too. As Cohen reported about $1,000 toothbrushes and $121 pacifiers I thought about my own horror story. Physicians aren’t exempt from illness and in 2008 I developed an acute eye condition that threatened my vision. At the recommendation of my optometrist, I saw a retinal specialist who admitted me to a local hospital for a same day procedure. In retrospect, I regret both having the procedure (that failed) and being admitted to an institution that provided less than exemplary customer service and gave me a over inflated bill.
As a physician, I know exactly what medication costs and was incensed when I received my $13,000 hospital bill. Charges of $181.00 for a $4.00 generic drug, implausible costs for intravenous medications and “Star- Wars-type” surgical tools made me see red. I challenged the outrageous bill but to no avail. I went through layers of billing clerks who were both rude and useless; and spoke with a hospital auditor who defended the charges. I complained vehemently to my insurance company, advising them that they were being duped but they paid their portion and never investigated my complaints. I ultimately paid my portion of the bill but felt like I had been extorted by the Mafia. In retrospect, here’s what I wish I had done:
- Requested an estimate of hospital charges BEFORE I was admitted
- Wrote a letter of complaint to my state’s Insurance Commissioner; and
- Consulted the services of a medical billing advocate
Most pregnant women will give birth either in a hospital or birthing center so it behooves you to be as pro-active as possible regarding scrutinizing your bill. Healthcare has become a business. Make sure you’re an educated consumer.