The obstetrician/gynecologist as the enemy

Before you read this, you should know a few things about me.  Unlike the above picture, I am female and nowhere near as good looking as he is (or as young), I don’t play golf and I sincerely hope that I am not evil or money grubbing. But the target on his chest and the horns seemed appropriate for this post. Last week I read a study that 9 out of 10 physicians currently in practice are unhappy with their jobs and would not recommend medicine as a career choice for their children.  I smugly realized that I was one of the minority, loved my job and would strongly recommend it to anyone. Reality this past week has a way of taking away some of the smugness. In the study, most of the reasons cited by physicians that led to dissatisfaction included paperwork, dealing with insurance companies and lack of time to spend with patients. I too do not like paperwork, but that is a necessary part of most jobs, not just physicians.  The business office at my clinic deals with insurance companies and I rarely need to get involved. I am able to spend the needed amount of time with most patients and use phone calls and email to complete what may not have been answered in the office.  Sadly, the interaction with some patients the past few weeks has been what has made my job less desirable.  The final straw was a blog post that was forwarded on from a nursing friend.

Last week numerous patients  called and had been advised by their nutritionist/chiropractor to have a large panel of labs drawn in order to find a cause for their fatigue, depression or weight gain.  There is no evidence in the medical literature to support most of these tests, which is what I try to explain to patients. I also try to focus on improvements in lifestyle – diet, exercise, sleep – which are harder than taking a pill but have been shown to work for all of the above.  Unfortunately, these patients chose to believe their other provider over my explanation and became angry when I declined to order the tests.

Obesity in pregnancy has become an epidemic  and  been shown to markedly increase poor outcomes in pregnancy in addition to increasing the cesarean rate. Conversations about personal weight are never easy and even more fraught with emotion when a patient is pregnant.  Many patients become defensive and focus their displeasure back on the physician who initiated the discussion.  It would be easier to avoid the topic and treat it like the “elephant in the middle of the room”, but then I am not doing my job as a physician should.  My angry patient last week choose to write a complaint letter to the clinic when we had such a discussion.

Via facebook, a friend shared a blog post from a post-partum patient detailing her experiences with a doula.  Doulas (labor companions)  can be very helpful to a laboring patient, especially when the patient does not have a supportive family or the partner is supportive but squeamish about medical matters. Unfortunately, they can also be obstructionist, as the doula in the blog, countering the advice of the physician and putting the patient in the middle. This makes my job much more difficult as I try to navigate honoring the role of the doula while also taking care of the patient and unborn infant in the safest way possible. Reading the blog post,  much worse than any experience I have ever had with a doula, brought back the memories of deliveries where the obstetrician is considered the “enemy” from the time they walk in the room.

One of our local hospitals heeded the advice of both the national pediatric and obstetric associations and stopped water births due to evidence showing that it can be more harmful to the newborn infant.  I do not perform water births, so the news did not affect my practice, but watching some of the tv reports and newspaper articles made me cringe. Many women are angry that their “choice” for delivery method was removed and are looking for other hospitals that still perform water births. I have had obstetric patients leave our practice in the past because we would not honor their choice of delivery, which has included water birth but also allowing the father to perform the delivery (Why have an obstetrician then?). Other patients and their families become angry when we limit the amount of people that can be present in the room for delivery.

As a parent myself, I am comfortable with being disliked on any given day as I know that it is in the best interests of my children for me to do what is best for them in the long-term and not be their best friend in the short-term. This is how I look at my relationships with my patients. In order to do the best I can for their long term health, it is my duty to have those difficult discussions about weight, to not perform medical procedures that may be harmful and not beneficial.  But recent changes in how physicians are being paid makes this a more difficult dilemma. In the near future, some of our reimbursement from insurance companies will be related to patient satisfaction. The patient who is upset that I won’t draw what I consider unindicated lab tests won’t be giving me a five star rating. Neither will the patient who is upset that I only allowed 4 of her 10 family members to stay in the room for her child’s birth. Early studies have already shown that when physicians are paid based on patient satisfaction, there is an increase in prescribing of narcotics and unnecessary antibiotics. I hope that the future is a balanced approach between patient satisfaction and trying to explain to our patients what is best for their health based on current medical research.



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