In his influential book, A Checklist Manifesto, Dr. Atul Gawande describes how simple checklists can revolutionize medicine. The use of hospital checklists has already produced significant benefits including fewer surgical mishaps, and lower infection and hospital complication rates. Most checklists are simple and easy to understand, so outside review organizations have embraced them in the practice of medicine.
But improving medical care through checklists is not the sum and substance of practicing medicine, which requires accurate interpretation of patients’ signs and symptoms, awareness and ability to assess treatment risks, and very often a sixth sense of when to act. Guidelines and protocols only describe these intangibles incompletely. As such, they are the GPS of medicine – they can make the journey easier, but it’s best having a professional who knows the territory and terrain.
A current case in point is the plight of obstetricians/gynecologists, specifically regarding Caesarean section and the timing of delivery. The American C-section rate has risen from 5% in 1970 to 32% today, a trend common to other parts of the world with similarly high rates (and little financial incentive to perform C-sections) including South America, China, and Europe. When deciding to perform C-sections, physicians are responsible for the well-being of mother and baby; this means accounting for many complex factors. In the US, the reasons for the C-section increase are primarily medical - greater use of drugs to induce labor, older and heavier mothers, higher rates of diabetes and other maternal diseases. An important nonmedical reason is the litigious environment, obstetrics being a fertile area (no pun intended) of medical malpractice claims; many physicians believe C-section reduces the risk of being sued.
Physicians also use fetal monitoring more often than in the past which has created a concomitant trend toward delivery before the “ideal” delivery date of 39 weeks. This is problematic because babies born before 39 weeks have higher incidences of death, neurologic, and pulmonary problems. Nationwide, neonatal intensive care units nationwide are experiencing greater rates of admission, a tragic and extremely expensive problem. Understandably, the Government, the American College of Obstetrics and Gynecologists, and the JCAH have all put in motion efforts to decrease the rate of C-section and eliminate non-medically indicated deliveries before 39 weeks. On its face, this would seem to be a “no-brainer”
But it’s not that simple.
Some Ob/Gyns worry the drive to manage how and when delivery should occur could become a heavy-handed mandate tying doctors’ hands. This concern deserves a hearing for several reasons. First, while earlier delivery and C-section result in greater neonatal morbidity and mortality only after the baby has been delivered, some literature suggests there are babies who would otherwise die in the womb that can be saved by delivery at 37 or 38 weeks. Hence, the decision when to deliver becomes a delicate balance. Second, “non-medical” indications can be vague; some diseases of mother and fetus are subtle. To diagnose correctly and intervene requires knowledge and judgment. Finally, doctors in the trenches are understandably reluctant to be judged harshly by hospital quality indicator committees or the JCAH. Lawsuit or not, the physician attempting to do the right thing for the patient may find themselves abandoned if a delivery goes wrong.
The drive by outside organizations to improve obstetric and other medical care is commendable. But some doctors’ fears of procrustean rules preventing them from practicing in the right manner are also real. No organization currently mandates a specific C-section rate or time for delivery, but it is not hard to see how “one size fits all” recommendations might eventually become a standard of care. Doctors deal with the uniqueness of each case, honing their ability and skill to recognize inevitable outliers. They don’t want to see that ability hampered by a spate of rules and regulations.
In 1847, the man who ultimately became history’s most famous obstetrician, noticed pregnant women in Vienna were six times more likely to die if delivered by physicians than if delivered by midwives. Decades before the cause of infections was known, Ignaz Semmelweis realized the deaths were due to “putrid material”, i.e. bacteria, doctors unknowingly transmitted to women. He believed the doctors, who did not wear gloves and worked in the autopsy lab before going to the delivery area, picked up this material in the lab. He felt strongly that virtually all the deaths could be prevented if the doctors simply washed their hands with household bleach before attending the women (presaging Gawande’s checklists). Influential, but stubborn European obstetricians refused to wash their hands, reviled Semmelweis, and tragically destroyed his medical career.
Eventually, his controversial recommendation was vindicated, saving countless women. Today, reputation restored, he is recognized as the pioneer of hand-washing and antisepsis, a medical giant with clinics and a university named for him.
Critics point to the story of Semmelweis and his detractors as proof of the medical establishment’s longstanding arrogance and dogmatism. The indictment has some merit, but those who point miss something else in the story - the hero who revolutionized medicine was not some bureaucratic organization but a brilliant, iconoclastic physician. In the new organizational world where shadow practitioners may dictate medical rules though protocols, might the next Semmelweis go forever undiscovered?
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