The following article is being re-posted with permission from The Unnecesarean. The article was originally posted on January 11, 2011, as a part of the Defending Ourselves Against Defensive Medicine series. Dr. Henry Dorn is an Obstetrician-Gynecologist currently practicing in High Point, NC. Thank you to Jill and Dr. Dorn for allowing us to re-post this fantastic piece in which Dr. Dorn takes on the issue of ritual-based vs. evidence-based practice of medicine.

In 1974, the noted obstetrician Marcus Filshie published a review of the relatively new electronic fetal monitoring in the British Journal of Hospital Medicine. He stated, somewhat fatefully:

"Now that the appropriate technology is available, the obstetrician may virtually eliminate intrapartum stillbirths and reduce morbidity to a minimum."

Similar statements were made in the United States by leaders in the obstetrical community and headlines were created. Although there was significant evidence that spoke to the limitations of this technology, the obstetrical community and the general public leapt to embrace this new found "cure" for adverse neonatal outcomes. Certainly in an age in which man could travel to the moon, computers were becoming commonplace in academic settings and nuclear energy a reality, doctors should be able to reliably detect fetal distress and act upon it safely, sparing parents the grief of the past.

Likewise, ultrasounds have allowed us to peer into the womb, and into the bodies of our unborn children, allowing us to anticipate not only the gender of our babies, but also see things as subtle as heart or spine defects. Yet everyone knows a story of the girl who turned out to be a boy, despite our best imaging efforts, and the mixed feelings that that surprise engenders (pun intended).

Molecular biology has allowed us to go even further, and examine the blueprints of life in utero, allowing parents to prepare for a child with chromosomal issues, or reassuring those with family histories of hereditary disorders.

Altogether, ever advancing science has created a sense of control over what once had been a very insecure time for families and their caregivers. The idea that following the current best medical evidence will virtually guarantee best outcomes is an appealing extension of that new found power over nature, but is a belief system that is inherently flawed, and that fact is often not appreciated by those who are captivated by its seduction.

Joseph Campbell, the comparative mythologist noted that cultures which are the most subject to the variable forces of nature, such as seafaring peoples, have the most rituals, in order to exert some sense of control over the uncontrollable. The obstetrical community must fit that model, insisting on specific rituals of care, even in the absence of absolute evidence of their efficacy, in order to gain a sense of control and mastery of the birthing process. The fetal heart rate tracing is poured over like tea leaves or cast bones, and the doctor becomes the shaman.

This belief system has been preached to future physicians and obstetricians, who passed it along to their students until the whole culture of childbirth medicine became steeped in a religious-like belief in the power of the fetal monitor, labor curves, ultrasound measurements and the like. This belief is similarly conveyed to patients who are assured that if their pregnancy was managed according to the protocols developed by trusted researchers, their babies would be delivered without fail and without harm.

Reality, however, has proven otherwise. Despite close and continuous monitoring in labor by the best trained and most capable staff and doctors, babies still die suddenly, or are born with unexpected asphyxia, or unanticipated illness. Families feel bewildered and betrayed and seek explanation and often recourse. If the latest technology was employed, then certainly human error must have been the cause.

Trial lawyers turn physician's own promises against them and win huge lottery-like settlements, setting precedence, and further convincing the public that the fault was not in the system but in the individual caregiver.

If, however, one looks critically at the myriad of diagnostic methods, and treatments used by the modern obstetrician, it becomes quite clear that there is much that is uncertain and much we cannot control. Most experienced practitioners know this, but are often resistant to admit this to their patients and the public, but this lack of disclosure has a tendency to backfire.

This is not to say that modern obstetrics with all of its technologies and oft maligned "interventions" is without value. Huge numbers of babies and mothers have been saved by modern medical care, but the failure to admit to ourselves and the patients we serve that we cannot guarantee perfect outcomes does a disservice to us all. Bad things do happen to good doctors (and nurses, and midwives etc.) and the sooner everyone understands this, the sooner we can start practicing evidence-based medicine as opposed to ritual-based medicine.

Conversations need to start with recommendations and explanations of their rationale, but leave room for the ever present uncertainty of outcomes as well as factoring in the patients desires and apprehensions. I believe that "I don't know" are three of the most powerful words in medicine and should be used more often. Patients who don't want to hear this need to realize that any practitioner who believes that they truly KNOW anything for certain is more dangerous than the one that makes allowances for the great amount of variability that life entails.

This more open communication should certainly help to restore the trust patients once had in their providers, and begin the process of reducing costs due to defensive medicine, as well as lessen patients' sense of betrayal that sometimes occurs with unexpected bad outcomes.

Posted By: Dr. Henry Dorn, c/o Kimmelin Hull, PA LCCE

Published: January 23, 2011

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