Legislating Mandatory Malpractice

Let’s Stop Making Ob/Gyns the Sacrificial Lambs of American Healthcare

The Alabama IVF embryos-are-children decision is the most recent example of how obstetrician-gynecologists have become the sacrificial lambs of American healthcare, not asked but told to ignore everything that they know about how best to care for women who plan to be or are pregnant.

Doctors have a straightforward job description: to relieve suffering, save lives, and cure disease, combining centuries of accumulated medical knowledge with new insights gained from modern technology to practice at the highest standard.

Unless they are ob/gyns in the United States.

In which case they need to solve for one more simultaneous equation, one that has nothing to do with science, health, or best practices medical care; indeed, an equation that tells our ob/gyns to ignore the best interests of their patient and commit malpractice, or risk criminal culpability, to ignore years of training, grounded in science and the collective experience of generations of others and tell your patient to her face that you are needlessly putting her in danger.

How jarring is this to practicing obstetricians? Let’s put it in context.

Consider the beta book.

The beta (short for the beta subunit of human chorionic gonadotropin, the hormone measure in a pregnancy test) book was a spiral notebook that the chief resident on the obstetrics service carried at all times, that kept track of any patient that we had seen, whether private or clinic, whom we suspected might have a pregnancy that was developing abnormally — maybe a pending miscarriage, maybe a tubal pregnancy, but was too early to tell.

Most of these pregnancies progressed normally, but others, if left unattended to, could cause life-threatening bleeding or sepsis, or internal organ rupture. In the 1980s, as our hormonal blood tests and ultrasound scans made early pregnancy diagnosis more precise, our drive to make sure that no patient, anywhere in the New York Hospital — Cornell Medical Center system, suffered unnecessarily.

We learned about the beta book on the first day of internship, part of our orientation to the more dangerous aspects of childbearing. Pregnancy care changed a lot during my training in ob/gyn and reproductive endocrinology. Sedation and forceps disappeared; delivery operating rooms transformed into birthing rooms with curtains and couches, and the expected fathers and partners were no longer warehoused in a smoke-filled waiting room, passively waiting to be told whether it was a boy or a girl.

On the medical care side, we had new tools to detect and prevent obstetrical catastrophes that had plagued women for 3000 centuries: ruptured tubal and abdominal pregnancies, hemorrhage, or sepsis from incomplete abortion (“abortion” referring to the traditional obstetrical term of an early pregnancy that is partially or totally expelled on its own, not the more common term referring to the medical or surgical termination of a pregnancy.)

There was no greater crime to a New York Hospital ob/gyn resident than losing track of a suspected tubal pregnancy and then having her present days later in shock and bleeding internally. No one was discharged without an entry into the beta book. Did we have a previous hormone level, with which to reassure ourselves that things are progressing normally? No? Then write this one down next to the patient’s name and phone number and make sure she has another level checked in two days. Did we have a level already? Was the rise appropriate or was this pregnancy already showing signs of slowed growth or abnormal development site.

If it was a likely ectopic, the patient went to the operating room for a laparoscopy.

“Never sleep on an ectopic pregnancy,” the old-timers said.

If you had told one of us back in 1986 to ignore the beta book and discharge a patient with a known tubal pregnancy or one who is hemorrhaging and going into shock, or with an infected miscarrying pregnancy that could progress to life-threatening sepsis, we would be inclined to wheel her into the operating room anyway, to make up a fake diagnosis or misreport the ultrasound finding (“no fetal heart seen”).

To do otherwise would have been both malpractice and, to quote one of my much older colleagues from back then, “piss poor medicine,” which, in 1986, meant getting berated by the chief resident and shamed at the mortality and morbidity conference in front of the entire department.

Fast forward to now.

Is there another field in medicine where those outside the field, with minimal or no knowledge of how the human body works, negate the standard of care and tell those on the front lines how to practice? To ignore the cure for disease and relieve suffering standard that has guided medicine since the days of Hippocrates?

A Texas law overrules the covering ob/gyn in an emergency department, sending a hemorrhaging patient with an inevitable miscarriage to the parking lot, where she can go into shock, needlessly demonstrate that her condition is truly life-threatening, at which time the state is less likely to arrest and prosecute the doctor for trying to save the patient’s life.

Truly piss-poor obstetrical care.

Now we have a state Supreme Court mandating piss-poor IVF practice. Make one embryo at a time and prolong the time to pregnancy by months or years, making it even more difficult for women with infertility or habitual pregnancy loss or cancer survivors with frozen eggs or families at high risk for serious, fatal inherited disease to have healthy children.

Who benefits from the criminalization of mainstream obstetrical care? What part of the medical school curriculum is the next target for legislative or judicial takeover of medical decision-making? What part of our ob/gyns’ already complex job will we needlessly complicate, forcing doctors into impossible choices between their patients’ well-being and risks to themselves?

Neither our obstetrician-gynecologists nor their patients should bear the burden of capricious demonization of good medical care.