Thursday, October 12, 2006
Gotta love Dr. Gawande. Dr. Pho yesterday linked to a New Yorker article about "how childbirth went industrial" :THE SCORE. What follows is a informative look a the history of obstetrics (which I highly encourage you to read) and how things as forceps delivery and the Apgar score have improved outcomes for both mothers and babies:
Around the world, virtually every child born in a hospital had an Apgar score recorded at one minute after birth and at five minutes after birth. It quickly became clear that a baby with a terrible Apgar score at one minute could often be resuscitated—with measures like oxygen and warming—to an excellent score at five minutes. Spinal and then epidural anesthesia were found to produce babies with better scores than general anesthesia. Neonatal intensive-care units sprang into existence. Prenatal ultrasound came into use to detect problems for deliveries in advance. Fetal heart monitors became standard. Over the years, hundreds of adjustments in care were made, resulting in what’s sometimes called “the obstetrics package.” And that package has produced dramatic results. In the United States today, a full-term baby dies in just one out of five hundred childbirths, and a mother dies in one in ten thousand. If the statistics of 1940 had persisted, fifteen thousand mothers would have died last year (instead of fewer than five hundred)—and a hundred and twenty thousand newborns (instead of one-sixth that number).So along with anesthesia they have improved their oucomes. But according to Dr. Gawande the approach does not exactly fit the conventional "evidence based" approach:
In obstetrics, meanwhile, if a strategy seemed worth trying doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved. Obstetrics went about improving the same way Toyota and General Electric did: on the fly, but always paying attention to the results and trying to better them. And it worked. Whether all the adjustments and innovations of the obstetrics package are necessary and beneficial may remain unclear—routine fetal heart monitoring is still controversial, for example. But the package as a whole has made child delivery demonstrably safer and safer, and it has done so despite the increasing age, obesity, and consequent health problems of pregnant mothers.But with the ease one can figure an Apgar score, and obtain a "whole picture" assesment of the baby's status, comparisons will be made. And that has a wide impact: (emphasis mine)
The Apgar effect wasn’t just a matter of giving clinicians a quick objective read of how they had done. The score also changed the choices they made about how to do better. When chiefs of obstetrics services began poring over the Apgar results of their doctors and midwives, they started to think like a bread-factory manager taking stock of how many loaves the bakers burned. They both want solutions that will lift the results of every employee, from the novice to the most experienced. That means sometimes choosing reliability over the possibility of occasional perfection.And some things are easier taught than others.
The main point, and main question, of the article IMHO lies here:The fate of the forceps is a revealing example. I spoke to Dr. Watson Bowes, Jr., an emeritus professor of obstetrics at the University of North Carolina and the author of a widely read textbook chapter on forceps technique. He started practicing in the nineteen-sixties, when fewer than five per cent of deliveries were by C-section and more than forty per cent were with forceps. Yes, he said, many studies did show fabulous results for forceps. But they only showed how well forceps deliveries could go in the hands of highly experienced obstetricians at large hospitals. Meanwhile, the profession was being held responsible for improving Apgar scores and mortality rates for new-borns everywhere—at hospitals small and large, with doctors of all levels of experience.
“Forceps deliveries are very difficult to teach—much more difficult than a C-section,” Bowes said. “With a C-section, you stand across from the learner. You can see exactly what the person is doing. You can say, ‘Not there. There.’ With the forceps, though, there is a feel that is very hard to teach.” Just putting the forceps on a baby’s head is tricky. You have to choose the right one for the shape of the mother’s pelvis and the size of the child’s head—and there are at least half a dozen types of forceps. You have to slide the blades symmetrically along the sides, travelling exactly in the space between the ears and the eyes and over the cheekbones. “For most residents, it took two or three years of training to get this consistently right,” he said. Then a doctor must apply forces of both traction and compression—pulling, his chapter explained, with an average of forty to seventy pounds of axial force and five pounds of fetal skull compression. “When you put tension on the forceps, you should have some sense that there is movement.” Too much force, and skin can tear, the skull can fracture, a fatal brain hemorrhage may result. “Some residents had a real feel for it,” Bowes said. “Others didn’t.”
The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills—the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands.This is what is meant by "industrial medicine". Protocol-driven, evidence-based plans for what ails you. Because of this the vast majority of patients will be treated the same way for the same condition wherever they are. Some friends of mine have a child with lymphoma and they asked me if they should get treatment from the pediatric oncologist here or go to a referral center. Because of what I have described above I reccommended they remain here. The treatment will be the same and they (and their child) can remain at home surrounded by familiarity and people to help them.
But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.
The diagnosis of appendicits used to require years of training and experience, to know how to examine a patient and pick up on the subtle cues to determine the diagnosis, along with a few bad outcomes to provide negative re-enforcement. Now with CT scanners the diagnosis is made quickly and often before the surgeon is involved. Are there still "superstars" out there? Yes, and has been pointed out here before with certain procedures, volume makes a big difference. But in the performance of common procedures the difference between "great" and "good enough" is small. Don't belive me? Ask this guy. With the technology that exists (plugs and patches) your workaday general surgeon can approach recurrence rates that rival the Shouldice Hospital, without the trip to Canada.
Back to the article:
Yet there’s also no getting around C-sections. We have reached the point that, when there’s any question of delivery risk, the Cesarean is what clinicians turn to—it’s simply the most reliable option. If a mother is carrying a baby more than ten pounds in size, if she’s had a C-section before, if the baby is lying sideways or in a breech position, if she has twins, if any number of potentially difficult situations for delivery arise, the standard of care requires that a midwife or an obstetrician at least offer a Cesarean section. Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth.
I asked Dr. Bowes how he would have handled obstructed deliveries like Rourke’s back in the sixties. His first recourse, as you’d expect, would have included forceps. He had delivered more than a thousand babies with forceps, he said, with a rate of neonatal injury as good as or better than with Cesarean sections, and a far faster recovery for the mothers. Had Rourke been under his care, the odds are excellent that she could have delivered safely without surgery. But Bowes is a virtuoso of a difficult instrument. When the protocols of his profession changed, so did he. “As a professor, you have to be a role model. You don’t want to be the cowboy who goes in to do something that your residents are not going to be able to do,” he told me. “And there was always uncertainty.” Even he had to worry that, someday, his judgment and skill would fail him.
These were the rules of the factory floor. To discourage the inexpert from using forceps—along with all those eponymous maneuvers—obstetrics had to discourage everyone from using them. When Bowes finished his career, in 1999, he had a twenty-four-per-cent Cesarean rate, just like the rest of his colleagues. He has little doubt that he’d be approaching thirty per cent, like his colleagues today, if he were still practicing.
Will mediocraty be the norm? Only time will tell. |
