Defending defensive medicine

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Recently Amber wrote on the my Facebook page:

Can you adress the issue of over-medicalized births and malpractice? You make some very strong arguments against the “natural” childbirth movement but you haven’t discussed why women are looking for new options.

Amber is asking about defensive medicine.

Defensive medicine offers real benefits to patients.

According to Wikipedia:

Defensive medicine … refers to the practice of recommending a diagnostic test or treatment that is not necessarily the best option for the patient, but … to protect the physician against the patient as potential plaintiff…

Defensive medicine takes two main forms: assurance behavior and avoidance behavior. Assurance behavior involves the charging of additional, unnecessary services in order to a) reduce adverse outcomes, b) deter patients from filing medical malpractice claims, or c) provide documented evidence that the practitioner is practicing according to the standard of care, so that if, in the future, legal action is initiated, liability can be pre-empted. Avoidance behavior occurs when providers refuse to participate in high risk procedures or circumstances.

What about defensive medicine in obstetrics?

Consider the high rate of C-sections and inductions. They satisfy the requirements of assurance behavior.

Reducing adverse outcomes? Check.
Deterring medical malpractice claims? Check.
Pre-empting liability? Check.

Consider the precipitous decline in the rate of VBAC. That’s avoidance behavior: malpractice insurers have forced providers and hospitals to refuse to participate in VBACs.

There’s an important subtext that undergirds defensive medicine that often goes unrecognized and therefore unanalyzed. Defensive medicine is driven by the fact that we live in a “risk society,” a society that is organized around a new understanding of risk.

There have always been risks, of course, but they have traditionally been viewed as outside the control of human beings — the risk of a hurricane or other natural disaster for instance. The risk society has arisen because of new beliefs that we can and (especially) that we should control every aspect of risk.

In our risk society, we are obsessed with the risk of auto accidents and outfit our cars with ever more airbags and safety features. We are obsessed with risks to our children, and restrict their play outdoors and their independence, and we are obsessed with illness and death, literally passing laws to control personal habits like smoking.

How does the “risk society” impact obstetrics? We have become obsessed with the perfect child, and we construct ever more elaborate requirements to ensure that everything we do contributes to the perfect outcome.

But childbirth is inherently dangerous, especially for babies. Indeed, it has been the leading cause of death of babies, and one of the leading causes of death of young women in every time, place and culture. The most dangerous day of the entire eighteen years of childhood is the day of birth. The “risk society” demands that we do everything possible to reduce those risks to zero.

Lay people often conceptualize risk as a dichotomy: an individual is either low risk (it won’t happen) or high risk (it will happen). But that’s not how risk works. Risk exists on a continuum; the risk varies from person to person depending on a complex interaction of numerous factors. What’s the risk that a baby will die of group B strep meningitis? That depends on the presence of GBS in the mother’s vagina, the exposure of the baby when delivered, and the presence or absence of antibiotics. We can determine the risk of GBS meningitis in large populations, but for the individual woman who carries GBS, we cannot predict the risk that her infant will be infected.

What does this have to do with defensive medicine? Consider that in our risk society we are supposed to reduce our risk to zero. How do we do that? We do that by acting to reduce risk regardless of how small the risk might be.

That represents an entirely new approach. Until the advent of the risk society, we determined which tests and procedures to use by establishing a risk threshold. For example, we know that the risk of stillbirth begins to rise in the last weeks of pregnancy (from about 36 weeks onward). The risk of stillbirth begins to increase precipitous at 42 weeks. So we arbitrarily established the risk threshold for postdates induction at 42 weeks.

Lay people, with their dichotomous view of risk, tend to imagine that there is no risk of stillbirth prior to 42 weeks, and there is a risk of stillbirth after 42 weeks. But the reality is that risk exists on a continuum. Defensive medicine can best be conceptualized at lowering the risk threshold. In the case of induction, the risk of stillbirth starts rising long before 42 weeks. Since the risk society mandates that we reduce risk to zero, doctors feel they have no choice but to offer postdates induction to women by 41 weeks, or even 40 weeks. That’s really the only way to reduce the risk to zero.

This is a critical point. Lay people imagine that defensive medicine offers no benefits to patients and is undertaken solely to protect doctors, but that’s not a complete picture. Defensive medicine is simply lowering the risk threshold. It benefits patients in that the risk of a particular outcome (like postdates stillbirth) is reduced as far as it can be reduced.

So what’s wrong with defensive medicine? Defensive medicine rests on the premise that we must do things to reduce risk. It completely ignores the risks posed by doing things. But that’s not only a feature of defensive medicine, it is a feature of every aspect of a risk society.

Yes, we make cars safer by putting in more safety features, but we increase the price of cars. Yes, we reduce the risk of kidnapping if we don’t let our children play outdoors, but it’s not good for children to grow up cowering inside their houses. Yes, we reduce the risk of illness when we pass laws regulating private habits, but we also reduce freedom. And when we perform more C-sections we lower the risk of neonatal death, but raise the risk of maternal complications.

In our risk society, though, we apparently don’t care. We consider ourselves required to reduce risk of neonatal injury and death to zero, regardless of the other risks or costs that increase as a result.

Where does that leave us in regard to defensive medicine?

First, we can see that defensive medicine is not the use of tests and procedures on people who don’t need them. It’s lowering the risk threshold for using tests and procedures that we previously reserved for higher risk individuals.

Second, defensive medicine is not really a medical issue, but rather a societal issue. To reduce defensive medicine, we would need to give up the idea that we can and should reduce all risk to zero. We would need to recognize that there are negative consequences to reducing risk, as well as positive ones. Most important, we need to figure out how much risk we are willing to tolerate. Zero risk is not achievable, and the price for attempting to achieve it can be very high.

What does this mean for natural childbirth advocates?

First it means an acknowledgement that childbirth is inherently dangerous and that there is nothing trustworthy about birth.

Second, it means that each individual has to determine how much risk she is willing to tolerate and communicate that to her doctor or midwife. Pretending that complications will not happen to you (“trust birth”) is not a strategy; it’s an abrogation of personal responsibility. You cannot give informed refusal to interventions to protect your baby from the risks of childbirth by pretending they are never necessary since that flies in the face of reality.

Finally, it means that blaming doctors for defensive medicine not only isn’t working, but it can’t work. If you want to know the reason for defensive medicine, look in the mirror. Defensive medicine would not exist without the willingness of women to sue for anything less than a perfect outcome.

  • Inmara

    And then there are countries with single-payer healthcare system and without malpractice insurance whatsoever, where doctors can gamble with risks and outcomes and nobody will be held responsible. Even in case of clear medical negligence suing for damage is futile, as courts are dragging for years and there is nothing you can take from the medical person who caused damage or even from hospital (which is funded by government, so altogether taxpayers would cover the costs).

  • lily

    I had one of those “unnecessary” tests. Grumbled about it all the way home, even though my insurance was paying in full. A week later I got results that they detected a very serious medical condition in it’s earliest stages. Saved me from possible death or at least a lengthy recovery process. They were able to do a n easy surgery and I just a week with a small hurting area where the incision was. Now I want them to give me all the tests.

  • mabelcruet

    Interesting post. I think it ties in with the ‘It won’t happen to me’ syndrome. People struggle to accept that they aren’t unique or special, and that bad things will happen to them over which they have no control. We gets obsessed by trade-offs, for example, I will maintain my weight at X and that means I won’t get arthritis, or I will attend my doctor regularly and so my pregnancy will have no complications. It’s this magical thinking, the ‘think positive and your dreams will come true’ way of approaching an issue that makes it so difficult to accept when things go wrong. If you have a magical belief that nothing would go wrong because you did your affirmations and you really, really believed in birth, then obviously when things go wrong, you have to find someone to blame. The fact that it may not be anyone’s fault and that it just happened doesn’t compute, because the belief is ‘it won’t happen to me because I Believe’. It’s easier to blame others than it is to accept your body is a lemon at vaginal birth, or at growing a good sized placenta, or at dealing with vaginal GBS or whatever.

  • Heidi_storage

    Nice post. It is tricky, because the instant someone suggests that certain resources are being overused, people start shrieking “Health care rationing!” and “Next it’ll be death panels!” Remember the kerfuffle over the USPTF recommendations to raise the age of mammography screening?

    On the one hand, I as an individual patient want the doctors to do darn well everything they can to ensure that I (and my baby) stay safe. On the other hand, after a certain point your absolute risk for X problem is low enough that you don’t necessarily want to embark on costly treatments that carry their own risks.

    Frankly, I would prefer a vaginal birth to a cesarean; I have recovered nicely from vaginal deliveries (was shoveling snow 8 days postpartum from Kid 2), and it took an ungodly long time for me to heal up from minor surgeries. But I trust my doctor to advise me if Kid 3 needs to come out via cesarean, even knowing that it may be an “unnecessarian” in retrospect. Nothing’s perfect.

    • SporkParade

      Unless the resource being overused is C-sections. In which case, women who request C-sections are wasting resources because they’re too “vain” to give birth the “right” way. [insert eye-roll here]

      Otherwise, you’re absolutely right, of course. I’ve lived in the US, and I’ve lived in a single-payer health system, and I can’t see Americans accepting that you can’t sue for malpractice at the drop of a hat and sometimes you just don’t get your preferred medical treatment.

  • CSN0116

    I read Amber’s question to you a few days ago and immediately thought:

    1. As in any profession, some OBs are just dicks. There *is* paternalism, degradation, an unwillingness to exert any decent bedside manner, or even compassion for that matter. I have refused to let an OB treat me before, in labor, due to her despicable fear-mongering attitude and total lack of scientific literature and statistical understanding.

    2. So, yes, that shit ^^^ does exist. BUT IT IS RARE. The BIGGER problem is that women have been fed unicorn shit about what birth actually is, or should be. It IS painful; it DOES leave scars (even the vaginal mode); it IS both short and long-term traumatizing. Pain of that intensity can traumatize a person (even more so when you intentionally forego pain relief).

    But women don’t believe that birth very likely WILL be all of those things, so when they go on to experience them under the care of the traditional hospital and OB, they de facto attribute the “failures” to those people and institutions. And those who have never given birth read all about this de facto demonization on every mommy-blog they join when they piss positive on a stick. NCB tells them that if they would have been able to move and eat, had mastered hyno-birthing, had a supportive doula, were submerged in water, were more educated about their rights as a patient …that none of it would have happened.

    Being logically and quite predictably traumatized from the totally-walked-right-into-it, set-up failures of the previous birth(s), they seek out alternative care in the future. Had many been realistic about what was about to happen to them, open and willing to embrace pain relief, more educated about the inherent RISKS of birth, the trauma may not be so prevalent, and the need to seek alternatives in the future not so necessary.

  • Roadstergal

    “Second, it means that each individual has to determine how much risk she is willing to tolerate and communicate that to her doctor or midwife.”

    And how do we get women to understand that? They have been conned into thinking they don’t have to make any tradeoffs, that risk doesn’t apply to them.

    • fiftyfifty1

      And then even if they do understand, how do we get anyone to stick to their decision? A woman may say that she is willing to tolerate more risk because of good reasons X, Y and Z, but then if she has a damaged baby, how will she pay for lifelong care without suing?

      • Azuran

        And then there’s all the issue of ‘informed consent’
        I do think more information should be handled to women on the possible intervention, complication, risk/benefits and such.
        But lets face it. Even if you start educating yourself on day 1 of pregnancy, you are never going to know everything that could possibly happen and be sufficiently educated about all the risk/benefits to make 100% absolutely educated decision on every possible complication.

        And then you add the urgency of the situation and the state of the mind of the mother, who is most likely in pain, exhausted, possibly on medication and very likely in a panic state over the well-being of her baby.

        Making a decision in those situation can be very hard. And afterwards, it makes sense that many of them can feel that they did not truly understand the situation or that they were pressured.
        Which puts OB in a huge grey area where they end up being damned if they do and damned if they don’t, with lawsuits in every direction.

        • BeatriceC

          The OB is in an even further pickle because even when she does try explain the risks, women have been conditioned by NCB to ignore or outright deny the risks as “fearmongering” on the part of the doctors.

      • Sarah

        Yes, I think Dr A’s post would have benefitted from an exploration of just why women in the US who end up with imperfect outcomes may be likely to sue. If you and/or your child require lifelong care thanks to birth complications, and like the large majority of the population you don’t have the funds for it, doesn’t take a genius to see what you’re going to do next.