May 16, 2011
“But for the grace of God go I.” My late aunt drilled that value into my six-year old head and it has never left. An article regarding a New York politician recently caught my attention. When New York State enacted a bill to ban the shackling of pregnant prisoners, a New York State Assemblywoman objected. The article goes on to discuss the case of Jeanna M. Graves, who, in 2002 was arrested on a drug charge and began a three year sentence. Graves was pregnant with twins and while in labor, was handcuffed during her entire C. Section. How utterly ridiculous.
Before a C. Section begins, a patient is usually given either an epidural or spinal anesthesia. On rare occasions, she is put to sleep with general anesthesia if the baby must be delivered emergently. On all accounts, the patient’s legs will either be numb from anesthesia or she will be sleeping. Why then does she need shackles? She’s certainly not in a position to run. Although I addressed this issue last August, it needs to be revisited again.
Women’s health and pregnancy should not be political agendas. I recently tweeted about another controversial article that blamed the reduced workforce in Memphis on teen pregnancy. Yes, it’s true that 49% of teen pregnancies are unplanned and unwanted but somehow the teens eventually mature and become productive human beings for the sake of their children. Our workforce problems stems from the outsourcing of U.S. jobs overseas, not teenage pregnancy.
Jeanna Graves was not perfect but neither did she commit a heinous crime. She used drugs and had a self-inflicted disease. In the course of my professional career, I have witnessed the most egregious acts corruption, fraud, deception and medical negligence, all under the rouse of helping the poor yet not one administrator ever left the building in shackles or seen the inside of a county jail.
Here’s a question for New Yorkers: Would you really elect someone who approves of shackles on pregnant to be your congressional representative?
April 4, 2011
This post is written as a follow-up to The Hijacking of Pregnant Women.
It is said that sometimes you have to rock the boat in order to shift the course of progress. Well today pregnant women have reason to celebrate. The winds of change are apparent.
Bowing under pressure, K-V Pharmaceutical Company reduced the price of Makena from $1500 to $690. Makena is the trade name for hydroxyprogesterone caproate or 17OHP. It is a drug recently approved by the Federal Drug Administration (FDA) to reduce premature deliveries before 37 weeks if it is given before 21 weeks gestation. It has been used for years as an off-label drug and costs approximately $10 to $20 to make by compound pharmacists. When the FDA gave K-V an exclusive right to manufacture the drug, their integrity flew out the window. The pricing strategy of K-V is a case study of corporate greed. Most drug companies will use the “research and development” logic to explain their rationale for marking up the cost of a drug. In the case of Makena, that excuse is valid. The research and development of Makena had already been done by Squibb Pharmaceuticals who had sold the drug for years. Is it any wonder why U.S. citizens will cross geographic borders and purchase drugs from their Canadian and Mexican neighbors?
Kudos are in order to the American College of Obstetricians and Gynecologists (ACOG) who took the lead in questioning K‑V’s pricing strategies. The Society of Maternal Fetal Medicine, the American Academy of Pediatricians, the National Medical Association, the American College of Midwives and the Association of Women’s Health and Obstetric and Neonatal Nurses should also take a bow. To their credit, ACOG refused to accept any advertising from K-V regarding Makena, a decision that reduced their potential revenue but saved the lives of future generations. The FDA is also to be commended for allowing compounding pharmacies to continue to produce 17OHP which means pregnant women can purchase the drug for $10 to $20 as opposed to the K-V $690.00 sticker price. What a moral victory.
Perhaps the infamous words of Mark Twain say it best: “Always do right. This will gratify some people and astonish the rest.”
A healthy pregnancy doesn’t just happen, it takes a smart mother who knows what to do.
March 30, 2011
I read an article in my local newspaper the other day that gave me reason to pause. The State of Florida intends to hand over 3 million Medicaid patients to managed care companies who will reduce payments to physicians and hospitals. In exchange for accepting these low payments for professional services, doctors are guaranteed through pending legislation that no matter what egregious errors they make, the patient will only receive a maximum of $250,000 in a medical malpractice lawsuit. This is definitely a “lose-lose” situation for patients.
Managed care is bad news for pregnant women. Extremely bad news. Every ultrasound, lab test and hospital admission that your physician or midwife orders on your behalf will have to be pre-approved by a gatekeeper who is on a mission to increase the profits of their company by reducing the amount of money that is spent on you. So you must therefore be on a mission to keep both you and your unborn baby out of harm’s way. How do you do that? Here are a few suggestions that are taken from The Smart Mothers Guide to a Better Pregnancy:
- Research your prospective healthcare provider through your State Board of Medicine’s licensing department to make certain they do not have any 7-figure malpractice suits settled or pending
- If you’ve had a previous high-risk pregnancy, request a referral to a Maternal Fetal Medicine high-risk specialist for your prenatal care
- If you delivered a preterm baby in the past, chances are likely you will do it again. Ask to have your cervix measured when you have an ultrasound and if it’s short , request a referral to a high-risk specialist
- If you have vaginal bleeding and are pregnant, do not leave a doctor’s office or an emergency room without someone doing an ultrasound to confirm that (a) the fetus is alive and (b) the pregnancy is not in the fallopian tubes (aka) ectopic pregnancy. An undiagnosed ectopic pregnancy could rupture and cause havoc.
- If you complain of a vaginal discharge, do not leave your healthcare provider until someone gives you a diagnosis and treatment. Untreated vaginal infections can lead to preterm labor. Bacteria is not your friend when you’re pregnant
- Back and lower abdominal pain should not be ignored, especially if you are less than 36 weeks. It could represent signs of premature labor
- Become familiar with fetal tracings. Flat lines and “u-shaped” curves during labor could mean your baby is in trouble and needs to be delivered quickly
- Try to deliver in a hospital that has a level 3 nursery and/or a NICU (neonatal intensive care unit)
- If a hospital mistreats you, contact its administrator. If you’re still not satisfied, file a complaint with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) http://www.jointcommission.org/
- Trust your instincts. I can’t emphasize this enough.
Prevention is the key to reducing medical injury, not taking away someone’s right to sue.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do. Check out the video below for my information and pick up a copy of The Smart Mother’s Guide
March 16, 2011
To everything there is a season and mine comes to an end today. For 760 weeks I attempted to give quality care to my patients. The task was not always easy especially when most of my patients held the unenviable position of having a high risk pregnancy and receiving Medicaid or being uninsured. Babies have a right to be born healthy regardless of their mothers’ income or insurance status.
The memories of my tenure at the county health department are indelible. I remember the woman who paid to be taken across the border only to be abandoned and walked from San Salvador to Texas. And the obese patient who rode a bicycle to the clinic with a blood pressure of 221/110. Of course she refused to go to the hospital because she alleged that they treated her “like dirt.” I begged, pleaded, and personally drove up the street to fill her blood pressure medication prescription to avoid her having a stroke or seizure in my exam room. My nurse found an ambulance company that was willing to take her to the high risk specialty hospital where she delivered prematurely in order to save her life and that of her baby’s.
And then there was dear Priscilla* (name changed) who had a bipolar breakdown and was about to be inappropriately discharged from the labor room triage until I advocated from my home around midnight and found her a hospital bed in my county where she was appropriately admitted, treated and subsequently delivered. There was also Katy* (name changed) who was sent home inappropriately with low fluid and subsequently went “on vacation.” I tracked her down in another state, told her to go to the nearest hospital where she was emergently admitted and delivered via c/s. My advocacy, diagnostic saves and battles with hospital clerks (who practice medicine without a license) continued for almost 15 years. It was difficult, stressful and at times frustrating, especially when the administration’s emphasis was on patient volume and money as opposed to quality patient care.
As this chapter of my life closes, I’d like to think that I’ve made a small but unique difference in the lives of others. I will indeed miss my patients, but I will not miss the stress. Service is the price we pay for being here. I hope I have served humanity well.
March 14, 2011
So, here we go again. Yet another slap in the face by big Pharma. Something is fundamentally wrong when a company charges $1,500.00 for a $10.00 drug that will not only save the lives of human beings but also reduce the annual $26 billion dollar cost of premature births.
Hydroxy progesterone caproate, marketed as Makena, has been around since 1956 and has been used for the past 15 to 20 years to help reduce premature births. It was originally manufactured by Squibb Pharmaceuticals but was removed from the market for reasons unknown. However, physicians were able to continue prescribing the drug by having it made in compound pharmacies for $10 to $15 per injection. The FDA subsequently gave KY Pharmaceuticals the exclusive right to produce the drug. Well, that was a glaring mistake. Why would the FDA want to give a company EXCLUSIVE rights to produce the drug? In a free market, competition is critical in keeping prices down. Twelve percent of births in the U.S. occur prematurely and a disproportionate number are African American women and teens. The drug has to be given between the 16 to 20th week of pregnancy and continued up until 36 weeks. Let’s do the math. The medicine has to be injected weekly. A patient taking the drug beginning at 16 weeks will have to continue taking it for approximately 20 weeks and 20 x $1500 =’s $30,000. So what originally costs $200 to $300 to prevent preterm pregnancy has now spiked to $30,000. How many different ways can we spell the word, GREED?
The prevention of premature births is paramount to the well-being of a newborn. Makena is not an optional drug. It will benefit many unborn babies and especially those whose mothers have a short cervix. Because Makena is now an FDA approved drug, the off-label brand previously made by compound pharmacists is not an option because of liability issues. Do you really think the insurance companies are going to pay $1500 for this drug?
I leave you with a profound quote from one of my readers, Dorice Arden:
“. . . a shocking reminder of just how low the value for humanity has sunk. The notion that patients are considered a commodity has far-reaching consequences. The very thread that ties us to our humanity is the value we place on life and life-sustaining measures. The attention and care we share with each other sets the tempo for the future.
Well said, Dorice. Well said.
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.
December 8, 2010
The day Elizabeth Edwards announced that she had breast cancer, my heart sank. Finding a lump in the breast only heightens the suspicion that the prognosis may not be good. In Elizabeth’s case, it wasn’t. We all admired Elizabeth for different reasons. In my case, it was her love for healthcare reform that quickly grabbed my attention and we were both older moms of two small children. Elizabeth advocated universal healthcare and comprehensive insurance for all Americans, not a “compromised” version based on partisanship and politics. As the years wore on, she discussed her diagnosis of incurable breast cancer with passion stating that she knew that she had access to the best possible care but empathized with women who were not as fortunate.
It is said that behind every successful man lies the power behind the throne and we know this to be true about Elizabeth. She was an accomplished attorney in her own right who took a back seat to raise her kids and support the presidential candidacy of her husband. For a while I thought Elizabeth had won the battle against breast cancer during its remission but then it resurfaced its ugly head in the midst of her husband’s presidential campaign. She handled it with both dignity and grace. We collectively winced when she faced the infamous scandal that violated principal and moral authority and embraced her even more. The last years of her life were a celebration of uncertainty as she became more and more vocal about healthcare reform. As recent as last night, members of our healthcare advocacy group, Doctors For America, discussed sending Elizabeth a letter of gratitude for all of her efforts regarding healthcare reform. Alas, we were too late. She made her transition this morning.
Elizabeth might have lost the battle with cancer, but she certainly mastered the art of living. In her own words she explained “I have found that in the simple act of living with hope, and in the daily effort to have a positive impact in the world, the days I do have are made all the more meaningful and precious. And for that I am grateful.”
We’re grateful, too, Elizabeth. Very grateful.
June 23, 2010
A recent Dutch study (see Birth Complications More Common at Night) of over 700,000 births revealed that newborn deaths and complications occurred more often at night which came as no surprise. In a make-believe- world, everyone would have a baby before the end of the day-shift in a fully-staffed hospital manned by people who are alert. But reality is a different story. Obstetrics is a specialty of the unexpected and women can spontaneously develop labor at the most inconvenient times within a 24-hour day. Yet, all is not lost. With proper recognition of potential red flags, a pregnant woman may have a wonderful delivery even if it’s at the most wretched hour of the night or early morning. Based on my years of clinical experience and medical malpractice case reviews, here are some tips worth remembering:
- Try to be admitted to a hospital where they have 24-hour anesthesia service to avoid waiting for them to arrive from home. If there’s an emergency, an “in-house” anesthesia department will save precious time.
- Try to deliver in a level 3 hospital has neonatology specialists in the event that you baby requires immediate specialized care after birth.
- Make sure your information is updated properly during the change of shifts. If your fetal tracing has been lousy during the past hour or your blood pressure has been elevated, the incoming staff should be made aware.
- Do not hesitate to ask about the whereabouts of the doctor or midwife if they are not in the hospital. By law, the admitting physician or midwife should be documenting your care by writing notes on a chart. Your physician or midwife has the ultimate responsibility for your care; not the nurse. If you’re in a teaching hospital and being managed by resident physicians, always ask to meet their supervisor, the attending physician.
- Ask whether you’re making progress in labor. If you’ve been the same number of centimeters for greater than two hours, there might be a problem with your labor.
Being in labor at night should no longer be a grave concern. When you are empowered with the proper information, the chances of encountering birth complications will be greatly reduced.
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!
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.