Reduce Dismissiveness, Reduce Maternal Mortalities

In 2010, Atul Gawande wrote The Checklist Manisfesto. This was back when electronic medical records (EMRs) were being forced upon medical practices by the government, not because such records improved patient care or a physician’s ability to diagnose. Rather Medicare wanted the data to keep track of the what medical practices were doing so they could control care with checklists. I’m a great admirer of Atul Gawande and I am not suggesting the conclusions drawn in his book were factually incorrect. My problem is with the title. At a time when the government was forcing medical practices to collect data irrelevant to the art of medicine, the title gives the impression that checklists will solve all kinds of problems in medicine. Checklists can solve some of the procedural problems with medicine, such as providing a protocol for washing hands, as Gawande discusses. A hand washing protocol—a checklist, if you will—can improve the safety of medical practice.

Not, however, the actual art of medicine.

I agree checklists have a place in medicine. But they can’t substitute for a physician’s knowledge of medicine. The art of medicine defies checklists. However, checklists morph into “healthcare systems,” which morph into all kinds of rules and regulations which actually worsen healthcare rather than improve it. The expert knowledge of physicians can’t be absorbed into a “systems” approach. Physician expertise is left lying on the cutting room floor while patients are denied access to needed healthcare by the rules, whether they be health insurance preauthorizations or the government’s insistence that no one is going to get a needed antibiotic or pain killer.

As the increasing maternal mortality rate in the U.S. gains more media attention, forming “teams” to take care of maternity patients have gained center stage. The belief seems to be that teams can somehow do a better job at spotting problems and taking corrective measures than individual physicians. Many of these teams are promoted as increasing the patient feeling of individual, personalized care. The missing element is how they increase a patient’s feeling of personalized care. I doubt that the families of women who die in childbirth would support this notion. My personal opinion is that “team” care is the problem in the first place.

About three years ago, I participated in Steve Harrison’s Publicity Summit. The topic I was trying to promote to the media specialists was the high maternal mortality rate in the U.S. and what we could do to bring it down. When I introduced myself and my topic, to my surprise, nobody wanted to hear about it. The media representatives were quite emphatic about talking about such awful news. Fortunately, in the past year or so, more and more preventable maternal mortality deaths have been reported in the news and it’s now a topic which is beginning to find its way into more and more reporter columns.       

Three years ago, I was just beginning to develop the idea of a pregnancy book to improve maternal and neonatal outcomes by providing women information about how to work with their physicians in having a safe pregnancy. To that end, I had made a video which was called “How to Avoid Losing Your Life in Childbirth.” Neither the video nor my idea for a book to put lifesaving information in the hands of pregnant women generated any media interest.

If you read the media stories, time after time the concerns of a woman or her husband over pain or bleeding were dismissed by those providing care. What’s really lacking in our care of pregnant women is access to care which doesn’t dismiss their complaints, or worse, blame them for the problem. In these media cases, someone decides it’s not necessary to call the doctor to come in and check on the patient. On the other hand, sometimes the doctor sends the patient home. Time and time again, I ask myself why obstetricians or surgeons wouldn’t check on their patients at least once a day. Or why the doctors wouldn’t recognize fetal distress. Nurses didn’t have to ask me to come in and check on my patients. I always saw my mothers every day, and saw them more often if I had concerns about their status. I was responsible for the health and safety of my patients, not someone on a “team” designated to check here and there and decide if I needed to be called. In a country like ours, with the most expensive healthcare on the planet and the largest glut of healthcare providers and machinery of any country, we fail miserably in our care of pregnant women.

Behavioral Health Deaths

The largest number of maternal deaths now occur in a group labeled “behavioral health.” These include suicide, homicide, and drug overdoses, intentional or unintentional. Several decades ago this group of maternal deaths didn’t appear on the list. According to the Centers for Disease Control and Prevention (CDC) 82 percent of the maternal deaths in the behavioral health category are patients who are either in or have been in mental health care in the previous year. This tells us that we are identifying pregnant women with behavioral health problems, but we are not treating them effectively. The story of Lindsay Clancy clearly shows she was having trouble with postpartum depression, knew it, and sought medical care several times, even admitting herself to a psychiatric hospital. Yet she didn’t receive the care she needed or she would not have killed her children.

Presently obstetricians taking the lead from ACOG (the American College of Obstetricians and Gynecologists) may make a nod to mental health by administering the Edinburgh scale. This scale is considered to be useful only in identifying depression. That is, the test does not detect depression unless the patient is depressed. These test results give no indication of whether or not the patient is at risk for depression. In my experience, postpartum depression does not respond very well to medication, as we have seen with Lindsey Clancy. My patients responded better to talking and working out solutions to the practical problems they faced in pregnancy and after the birth of their babies. There’s no checklist here, but in my experience, sitting down with patients and listening to them talk about their prenatal or postpartum problems can prevent postpartum depression.

There is no team member per se designated to sit down and talk over the concerns of women having problems with depression before and after birth. This is the doctor’s responsibility. In reality, the data collectors who created the EMR aren’t the least bit interested in this kind of information because it doesn’t fit a check box that can be turned into a reason to deny care. Furthermore, the 10-minute visit dictated by current healthcare managers makes it impossible for a physician to offer this kind of care without administrative threats to observe the 10-minute clinic visit limit or look for a job somewhere else.

The CDC further tells us that all of these deaths are considered to be avoidable. But the CDC admits no one can really say why the maternal mortality rate continues to rise. It seems to me if the CDC considers the deaths avoidable, there should be some way to figure out how to prevent them.    

Furthermore, my experience is that psychotropic medications are not going to help most moms who have a pregnancy-related depression or psychosis. A prime example is Lindsey Clancy. She had been put on 12 different psychotropic medications from October, 2022 through January, 2023 and strangled all three of her children anyway. Ativan helped her the most, but her physicians took that away because of the concern she might become “addicted.” Taking Ativan offers much less risk than the risk of strangling three children. So, the DEA triumphs once again with its checkist prescribing protocols, but the results of the DEA checklists don’t show up in the data.

Bleeding After Birth

After behavioral health, the second major cause of maternity-related death is bleeding. It’s hard to imagine that in this country where we have so much health care available, so much machinery, so much ability to do labs, so many nurses, and so many doctors, that patients can actually bleed to death in our hospitals. In 2016, Charles Johnson’s wife Kiri bled to death following her second C-section. This was her second pregnancy and she was healthy. This C-section should have been a slam-dunk, and that is exactly what Kiri and her husband were expecting. And why not, they were going to the well-known Cedars Sinai Hospital in Los Angeles. After her C-section, Kiri remained in the recovery room for at least 8 hours until she was returned to the operating room. After being returned to her room, Charles noticed his wife was turning pale and she had abdominal pain. He called the nurses in about 4:00 p.m. They told him they would order a stat (right away) CT of her abdomen. No one came to take Kiri to radiology for the CT scan. Of course, the CT wasn’t necessary, but it was an excuse to buy time and to placate Charles into thinking Kiri’s condition was actually going to be addressed. Charles continued asking the nurses for help. At 8:00 p.m., one of the nurses told Charles, “Mr. Johnson sir, your wife is not our priority at this time.” By midnight there was enough concern to return Kiri to the operating room. The doctor told Charles, “Sometimes these things happen. We’ll be done in 15 minutes.” 

     Kiri was given anesthesia and re-opened. They found 3.5 liters of blood in Kiri’s abdomen. That’s 70 percent of her total body blood volume. Kiri’s heart stopped on the operating table and could not be restarted. A repeat C-section is a simple surgery. Obviously, the original C-section was majorly flawed to cause this kind of bleeding.  If her return to the operating room had been done right away when the pain and bleeding were very evident to Charles, Kiri’s life might have been saved. Returns to the operating room “happen” and those are not considered to be a sin, but failure to recognize them and failure to repair them in a timely manner is a sin. So, there is absolutely no excuse for pregnant women to bleed to death in this country with our ability to provide care, including blood.  

System Failures

  Trouble getting access to needed healthcare is a systems failure. But there is a specific kind of denial that is our main problem. With a team of people providing care to a patient, no one takes responsibility for outcomes. It’s very easy for team failures to be determined to be nobody’s fault. Often the group of doctors who examine the case conclude, “Difficult case, managed well,” in order to of absolve themselves of any apparent group mess.

     In the end, the main problem in these stories of women dying appears over and over again—dismissiveness. The patient’s concerns are said to be of no concern, as we saw with Lindsey and Kiri. The problem here is represented by the nurse’s remark, “Sir, your wife is not our priority at this time.” Who made the determination that Kiri’s hemorrhaging and pain were not “our” priority? Even if someone had suggested that, the nurse should have been able to recognize the emergency and argued for immediate attention.

     Patient’s concerns should not be dismissed. Every patient needs their concerns addressed. For Kiri, rather than ordering a CT scan, the doctor could have been summoned to see the patient.  Finding post-operative bleeding is not rocket science. Repairing mistakes is the main responsibility of the original surgeon. Certainly, an excessively enlarged abdomen or excessive abdominal pain should get everyone’s attention. Responding to Mr. Johnson’s complaint at the right time might have saved Kiri’s life.

Dismissiveness Is A Systems Failure

My suggestion is that dismissiveness is a systems failure in healthcare. Most stories of maternal mortality will reflect patient concerns were ignored or misrepresented by caretakers and in the EMR. Because dismissiveness doesn’t fit any checklist boxes, it’s not recognized as a serious, significant problem with maternal mortalities.         

Atul Gawande’s The Checklist Manifest was a fine book, but it tends to give the impression that all medical problems can be solved with the right checklist. Listen up. They can’t. Our idolization of the EMR simply creates the notion that the art of medicine is contained in check boxes. The real art of medicine hit the cutting room floor with the destruction of the patient-physician relationship. Our horrendous maternal mortality rates will remain impervious to improvement until the healthcare system comes to terms with their folly and looks to the real reasons maternal mortality rates as much low in many developed countries.