The Art of Medicine Is Not in Your Video

The journal of the American College of Obstetricians and Gynecologists (ACOG) recently contained an article researching whether a video covering warning signs of dangerous postpartum conditions made available to women might reduce maternal mortality. To the authors’ credit, they recognized that part of the problem with maternal mortality may be caused by a patients’ lack of information about the warning signs of dangerous conditions:

When factors that contribute to maternal mortality are analyzed, individual factors, such as patients' lack of knowledge of warning signs and when to seek care, are among the most common. Addressing and improving patient knowledge may be an important strategy for reducing the risk of maternal mortality.

It is heartening to see that there may be some understanding that women may lack the knowledge of the symptoms of postpartum problems, but by the same token, it is depressing that this lack of knowledge occurs because the relationship between the women and their doctors did not include a discussion of these possible problems with patients. And most important of all, if a patient calls a doctor to report one of these warning signs, would the patient’s report be taken seriously? Corporate medicine has been very successful at destroying the relationship between doctor and patient, not just in obstetrics, but this destruction can be seen in the disappearance of primary care physicians. 

In this article, the most common causes of death during the first week postpartum are reported to be hemorrhage (18.8 percent), blood pressure disorders (16.9 percent), and infection (14.9 percent). Suicide accounts for 8.8 percent of all pregnancy-related deaths, with one in eight postpartum individuals reporting depressive symptoms.

Perhaps it’s just journalism or perhaps it’s just the most spectacular cases which hit the media. But if you read the stories in the media, pregnancy related deaths are often due to dismissiveness on the part of the nurses and doctors. I have written about how often patients recognize a problem, but the healthcare providers responsible for assessing patient health dismiss them. This is tragic.

Dismissiveness is a term applied when the caretakers don’t believe what the patient reports and thinks the patient is just imagining symptoms. One ProPublica article reports on a person of color who presented four times in her third trimester to labor and delivery with concerns about too little movement. The first three times the baby was living, and the patient was sent home. A nurse had apparently made a note in the chart that the patient just didn’t know how to assess fetal movements correctly. The fourth time the patient presented to labor and delivery the baby in her uterus was dead. The doctor came by and told her that she should have come in sooner. How can a doctor be so callous? Or did the doctor not know that the woman had been there three times and sent home? The lack of communication between a patient and her doctor is a systems problem, but no less tragic.  

Another version of dismissiveness is gaslighting—the provider bias of blaming the patient for the problem. Like dismissiveness, gaslighting kills.

I have written here before on how the high U.S. maternal death rate is no mystery.

I was not surprised to read that the results of the study indicate enhanced postpartum education through a video did not result in a statistically significant difference.

As I have said above, I’m happy that the young doctors and nurses are interested in lowering the maternal mortality rate. I am surprised to see their perception of what might be considered to be workable solution to be a video.

Today the only things on the chopping-block for good obstetrics are the things that should not be on the chopping-block, ever. Most important is the amount of time we spend with our patients forming what I call patient partnerships. There is nothing we can do that will outshine the value of a good relationship with our patients. Whether you are a midwife, family practice doctor, or obstetrician/gynecologist, you should see your patients regularly, as often as they need to be seen for as long as they need to be seen during their prenatal and the postpartum period, even up to a year or more. Presently, according to the standard of care, we see patients one time at six weeks postpartum to be sure the patient’s uterus has shrunk back to normal size.

If seeing the patient at six weeks to check the shrinking of the uterus is all the more we do, then we are irrelevant to the needs of our patients. I’ve always seen my patients for as many times as they needed to be seen, including postpartum. Presently we have a conspiracy of sorts, but not in the usual sense.

In other words, nobody has actually sat down and said we’re going to increase the maternal mortality rate, but neither have we done anything that will decrease the maternal mortality rate, and we also have done nothing to mitigate the problems we are facing, the ones which make our maternal mortality rate increase. We have payers threatening to pay less, employers (clinics and hospitals) telling us to see more patients in less time, ACOG telling us it’s acceptable to send in substitutes for our prenatal exams, and insurances telling us to kick patients out of their postpartum care before they are ready to go home.

Unfortunately, it’s been so long since we’ve been able to exercise the prerogative of sending patients home from the hospital when they’re ready that I suspect that not even the current teachers understand that it is the partnership with the patient that is missing in today’s pregnancy and postpartum care. The partnership idea has been gone so long that most people don’t even remember, let alone understand, the significance of how good care used to be.

An important part of postpartum care from 30 and 40 years ago was morning rounds, where we all got together to decide whether patients were ready to go home or not.

Back in 1988 our maternal mortality rate was 8/100,000 because we could keep our new moms hospitalized until they were ready to go home, be it 3, 4, or 5 days.

Think about it. The most common causes of death during the first week postpartum include hemorrhage, blood pressure disorders, and infection.  If doctors were allowed to keep their new mothers in the hospital for three to five days, the majority of the seven day high risk period, half of our maternal mortality patients with bleeding, high blood pressure and infection, could be identified and treated in the hospital.

A word to the wise. All serious conversations that you have with your patients must be done face-to-face, eye-to-eye, with an uninterrupted give-and-take discussion. That’s a partnership and it can’t be replaced by anything corporate medicine provides. More importantly, nothing bout this very important relationship appears in the electronic medical record. So this relationship is absent from the data everyone is so fond of collecting. The story relationship between doctor and patient is critical to patient safety.

The CDC says 60 to 80 percent of these deaths are avoidable. I would go a step further. My belief is that all of these deaths are 100 percent avoidable when a doctor is allowed to form a personal, trusting relationship with patients. The same kind of relationship primary care physicians used to be able to form with their patients before corporate medicine demanded visits be limited to 15 minutes and replaced primary care physicians in hospitals with hospitalists.

At the risk of being repetitive, tedious and boring, I’m going to say one more time:

“No person should die from hemorrhage, complications of preeclampsia, high blood pressure, strokes, or infection.”

Treatment is available for all of these things. It’s simply a matter of getting them diagnosed and treated at the right time.

All serious conversations with patients need to be done in person, not by video, not on the telephone, and not by one of the nurses or aids. The very best results occur when care is based on a partnership between the patient and the provider. Serious conversations, including informed consent, should never be done by a substitute.

Physicians who build partnerships with their patients can actually practice the art of medicine, but that lack of that art will go unrecognized as a cause of maternal mortality because it will never find its way into the almighty data bases of medical records.