Born in the USA (4 page)

As a result of my error, I went through a long soul-searching. I came to terms with my humanity and attempted to learn from the tragedy. The next time I encountered the same clinical situation, I immediately remembered the mistake—I had not done a tracheotomy quickly enough when a patient had a swelling obstructing the throat—and chose a different course, so that the second time around the patient didn't die.

There are serious problems with allowing doctors to deny that they sometimes make mistakes. Not only do they set themselves up to suffer from hubris, they create a situation where the concept of “clinical experience” can become nothing more than making the same mistakes over and over again with increasing confidence. Physicians do not learn from mistakes because they never make them. Another drawback: if doctors don't make mistakes, there's no need for them to accept responsibility for their practices. Under the current medical ethos, most doctors feel no guilt when their choices have a negative impact on patients.

I have had many discussions with obstetricians about the iatrogenic deaths of women and babies from rupture of the uterus after Cytotec induction in cases where the woman had previously had a cesarean section. It was a common practice in the 1990s and even the American College of Obstetricians and Gynecologists (ACOG) now strongly recommends against it. Yet I have heard no discussion among obstetricians (or from ACOG) of this mistake. When obstetricians discuss induction of labor with Cytotec, listen carefully. It is sad to say, but I have detected almost no remorse for this decade of scientifically unjustified practice, nor compassion for the women who suffered uterine rupture or lost their babies—no apologies, no sense whatsoever of obstetric responsibility, no mea culpa, only you-a culpa. Instead, it is common to hear attempts to justify the practice. Put simply, the response has been widespread denial.

That Cytotec induction was used for years on women with a previous cesarean section, long before adequate scientific studies determined that it was killing women and babies, could be an opportunity to learn from a terrible mistake. The situation serves as a prime example of why we need the FDA, why we need scientists, and why we must have evidence of safety before rushing to try a “hot” new drug or technology. But unless obstetricians can admit they made a mistake, there will be no lesson.
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If we accept Santayana's maxim that those who fail to remember the past are condemned to repeat it, we should not be surprised that this use of Cytotec represents one of many widespread iatrogenic tragedies in the history of obstetrics. I will discuss some of the more recent cases involving X-rays and drugs in
chapter 4
, but an earlier example is instructive as well. It dates back to the end of the eighteenth century, when women first began having babies in hospitals. There was an epidemic of women dying in hospitals during childbirth from an infection known as “childbed fever.” In 1795, the Scottish scientist Alexander Gordon, through systematic observations in hospital wards, proved the deaths were the result of doctors touching the
bodies of one laboring woman after another, without washing their hands, thus transferring deadly bacteria. Gordon was ignored. Fifty years later, in 1843, Oliver Wendell Holmes, a famous American medical doctor and professor at Harvard, published an essay agreeing with Gordon. Holmes's essay was also ignored. In 1847, the director of a maternity hospital in Vienna, Ignaz Semmelweiss, brought about a 6 percent drop in maternal mortality simply by requiring hand washing by all staff, doctors included. His reward? He lost his job and was driven out of town by hostile obstetricians who refused to believe the deaths of so many women could be their fault.

It was not until the 1880s, ninety years and many thousands of deaths after Gordon determined the cause of the epidemic, that hospitals and governments in the United States and Europe instituted regulations forcing doctors to wash their hands, leading to the abrupt end of “childbed fever.”
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When I mention epidemics resulting from faulty obstetric practices, many obstetricians are not contrite but angry with me for suggesting that members of their profession are not infallible. Obstetricians are not used to being challenged in this way by their peers. Among other doctors, obstetricians are treated as the supposed experts on pregnancy and birth, and that includes the family physicians who do maternity care. But, as we will see later in this chapter, the American Academy of Family Physicians recently parted company with ACOG when the latter organization made scientifically unfounded recommendations regarding vaginal birth after cesarean that have a negative impact on family physicians and families.

When doubt is expressed by a patient, it is all but intolerable. You can't imagine how upset many doctors become when a patient seeks a second opinion. They put a good face on it, but I've met countless physicians who feel that the doctor-patient relationship has been destroyed if a patient expresses less than 100 percent faith in their judgment. It's hard not to tease a group that takes itself so seriously. I like to wear a button that says, “Trust me, I'm a doctor.”

To understand how obstetricians come to believe that they are infallible, it is worthwhile to take a look at their training. The education students receive in medical school is not only medical, but social. We are taught how to behave as doctors and think as doctors. And we internalize the medical hierarchy.

I remember coming to class late one day in medical school. The professor was already demonstrating on a patient in the front of the lecture hall. He looked up when I came in, and said “Dr. Wagner, since you are late, come down and examine this patient.” (I was not yet a doctor, but part of
the indoctrination process is calling students “doctor” so they get used to thinking of themselves in that elevated position.) I replied, “I'm sorry, but I have forgotten my tools.” The professor slammed his fist on the lectern and shouted, “You are not a carpenter or plumber, you are a doctor! They are not tools, they are instruments.” Without thinking, I blurted out, “But I always thought doctors were one kind of plumber.”

I received the lowest possible passing grade in that course. When I complained that I had earned a better grade, the professor replied, “What do you care what your grade is? You're only going to become a general practitioner and for that you don't need top grades.” In truth, I had not decided to become a general practitioner, and the professor knew it. Saying that I had was a way of putting me down, as many medical school faculty members consider general practice to be at the bottom of the medical practice hierarchy, with lower status than any specialty.

Another classic demonstration of the medical hierarchy, which is well known by doctors and nurses but practically hidden from patients, is the dress code. In any given hospital or medical school, there are telltale signs that indicate exactly who's who. Believe it or not, all white coats are not alike. When I was in training at the UCLA hospital, medical students wore long unbuttoned white coats, for example, while interns wore short white coats with mandarin collars that buttoned down the side. “Residents”—graduated physicians in specialty training—wore short unbuttoned white coats, and faculty wore long white coats buttoned closed. Attending physicians wore no white coats at all. Medical school and specialty training are full of subtle lessons like these on status and hierarchy, on lording it over those under you and being subservient to those above, on “kissing up and kicking down.”

This hierarchy is reinforced within each specialty—including obstetrics. Over the years, I have also come to see that, in many respects, organized obstetrics has the characteristics of a primitive tribe.
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There is a long period of preparation for “manhood”—beginning with four fiercely competitive years in an undergraduate college, after which students start yet another four years of intense study in medical school. At UCLA, the medical school I attended, this phase of a doctor's life begins with an initiation ceremony—a rite of passage. Each student receives a symbol of his new status as a pledge in the tribe: the great white coat.

After eight years of undergraduate and medical school, initiates embark on a year of internship, and then go on to three or more years of specialty training in obstetrics and gynecology. It is no accident that those in specialty training are called “residents,” as their duties demand that, for all practical purposes,
they reside at the hospital due to long workdays and frequent on-call duty nights and weekends. In this phase of education, a doctor-in-training's world shrinks even further. He becomes more and more removed from normal life. Every day he is surrounded by elders whose job it is to teach him to think like an obstetrician. When his indoctrination is sufficient, he will go through his final initiation rite—examination by a “board” of elders and “board certification” as a member of the tribe. By the end of this educational purgatory, tribe members have developed strong feelings of loyalty to the tribe as a whole and to the tribal chieftains. From this point on, the greatest offense a tribe member can commit is not incompetence but disloyalty.

Armed with arrogance and a sense of entitlement, the young doctor enters the insular, protected world of obstetrics. He goes to local meetings of obstetricians or regional meetings of ACOG, and perhaps even occasionally attends national meetings of this organization. As he builds his practice, the young doctor will also be invited to obstetric “meetings” sponsored by pharmaceutical companies—meetings held on a cruise ship or at a ski resort, with a few hours each day devoted to lectures and the rest of the time for play.

In each of these various meetings, the obstetrician hears only the current obstetric dogma. As in everything else, there are fads in obstetrics and every dogma has its day. Participants may gain a bit of new knowledge at these meetings, but the key message is always, “We obstetricians know what we're doing, and we're doing it right.” This is the important function known as “preaching to the choir.” I have given many lectures at all kinds of obstetric meetings, and the fact that some of the ideas I present are outside the present obstetric orthodoxy always comes as a shock to the audience. As a clinician/scientist/epidemiologist, I give presentations that suggest a need to change certain practices. The response is always revealing. Typically, most doctors are so mired in and blinded by the obstetric establishment point of view that they react as if I have done a no-no in church by not reassuring them that all is well in our closed little world. But there are always some whose faces show confusion and concern as it begins to dawn on them that all might not be as right as they've been led to believe.

Obstetricians also spend much of their time in, and are heavily influenced by, hospitals. They go to a weekly “obstetric grand rounds,” a meeting to discuss cases with the other obstetricians on the staff of that hospital. A hospital is itself a closed society, and in my view, it is one of the last bastions of feudalism in our culture—complete with rigid regulations, hierarchies, and fiefdoms. Whether you're a doctor or a patient, when you go to a hospital in the United States, you leave a one-person, one-vote world
(messy, noisy, infuriating, but democratic) and enter a world where fear is the primary management tool and censorship and misinformation are standard practice. The maternity wards of America's fabled democratic society are anything but democratic.

In U.S. hospitals the hierarchies are absolute. Carrying on from medical school, obstetrics medical ethos dictates a clear ranking of all maternity care players—with obstetricians at the top, then hospital administrators, then midwives and nurses, and, at the bottom, patients. Naturally, those at the top tend to feel that any admiration or adulation directed to them is well deserved and they develop a certain scorn for those below. But in a hospital, this hierarchy is not just about status; it is about authority and control. I was once part of a group that, while preparing for an international conference on maternity care, drafted a document on humanizing birth that included the statement “Doctors and midwives must work together as equals.” The obstetric organizations that participated in the conference approved the entire document with the exception of those last two words.
As equals
was unacceptable within their hierarchy.

Still, the relative ranking of players in a hospital has never been so clear to me as it was when I experienced it as a layperson. Several years ago, while at a party, my partner twisted her leg while we were dancing, and her kneecap popped out, causing her extreme pain. I rushed her to the ER, where she was placed on a rolling table in a small room, and we were told to wait for the doctor. (I did not tell anyone that I am a physician.) She was completely miserable, so I climbed up on the table to hold her and comfort her. A nurse came by and told me to get off the table, even though we were alone in the room. Two hours later, a doctor applied a cast to my partner's leg, with the assistance of another nurse, and the two whispered to each other, giggled, touched, and carried on an open sexual flirtation while they worked. Their flirting didn't bother me, but it occurred to me that according to some unwritten hospital rule it was okay for doctors and nurses to display intimacy but not for patients to do so. I've come to believe that every doctor needs to experience being a patient in a hospital when the staff doesn't know the patient is a doctor so that he can see what it feels like to be at the bottom of the pecking order, instead of at the top.

Part of the reason for this belief in the hierarchy is that, in my experience, many practicing medical doctors live an insular life. They are not only limited in their contact at work, they tend to lead relatively insular personal lives as well. They, like other people providing individual services of a personal nature (police officers, mental health or family counselors, and so on),
seem to hang around with their own kind. They rarely have close friendships with people outside their own vocation. I believe this is at least in part because they have to keep “secrets” in their work. They can't share the truth of their experience with their clients/patients, so they learn not to share their experience with other outsiders as well. In daily practice, obstetricians usually talk only with other obstetricians or, when they must, with those they control—nurses, office staff, patients. Being an authority figure in such a cloistered world has inevitable results, the most common being a feeling that it's “us versus them.” And too often “us” rapidly becomes superior to “them.”