What makes a good doctor?

There are two important characteristics. The first is clinical skill: the ability to find a pattern in the patient’s signs and symptoms, the ability to identify the patter, and the judicious use of medical tests to fill in the blanks of the pattern. The second characteristic is compassion: the ability to care about the patient and empathize with his or her situation.

Many doctors have one or the other. Some of the greatest clinicians have excellent clinical skills, and poor bedside manner. And some of the most popular doctors have terrible clinical skills, but are easily able to deceive patients because they are kind and compassionate.

Both characteristics, whether alone or in combination, depend on one variable: time. Even the most clinically skilled doctor needs adequate time to listen to the patient, to elicit and think about all the relevant details of a patient’s situation. In the textbooks, diseases have straightforward signs and symptoms, and typical courses. As any doctor can tell you, patients don’t read the book. In other words, their signs and symptoms can vary from “textbook” descriptions or can be modified by other diseases or conditions that the patient might also have. And it goes without saying that the most important requirement for compassion is also time, the time to listen, empathize and offer comfort.

Yet if there is one thing that contemporary American doctors lack, it is time. That’s because the people who “manage” healthcare are obsessed with efficiency. In their minds, being efficient means seeing the most amount of patients in the smallest amount of time, as if efficiency in medicine should be measured by the number of patients “processed.” That’s not what it means to be efficient in the practice of medicine, though.

In medicine, efficiency means the ability to successfully treat as many patients as possible using only the tests and procedures necessary, and leaving the patients happy with their care. In the ultimate irony, the pressure to make doctors more efficient has made them progressively less efficient. That’s because no doctor can be efficient without adequate time to do the job. Simply put, no doctor can do a good job without spending substantial amounts of time meeting with and thinking about patients. Yet over the past quarter century, doctors have been pressured to devote ever smaller amounts of time to each patient, making doctors less, not more, efficient.

How have doctors become less efficient? All the evidence suggests that doctors make more mistakes, and order more unnecessary tests and procedures, without a concomittant rise in successful diagnoses or longer lifespan. Moreover, patients are increasingly dissatisfied with their care. Yes, patients are “processed” faster, but medical care has arguably gotten worse, not better.

The deterioration in the quality of medical care is directly linked to the reduced time that doctors spend with patients. Because a doctor has less time to talk with a patient, he or she is less likely to make the correct diagnosis. Because a doctor has less time to thoroughly examine a patient, he or she will order unnecessary medical tests to fill in the gaps. Because a doctor has less time to think about a patient, he or she is more likely to make an avoidable medical error. And, of course, when a doctor has less time to spend with a patient, he or she is more likely to be brusque and unsympathetic.

Good medical care takes time. Forcing doctors to see more patients in less time does not make them more efficient, because they can’t make diagnoses faster, examine patients faster, or think about them faster. They can only push them through the office faster. And that’s not efficiency.

My favorite part of practicing obstetrics was the moment of delivery, helping mom lift the baby to her chest and calling out, “It’s girl!” or “It’s a boy!” It was always a privilege to be part of the deeply personal moment when parents met their newborn child, and to share their joy and excitement.

Although parents are anxious to establish that the baby has ten fingers and ten toes, and is healthy in every way, the announcement of gender is often equally important. The knowledge of gender immediately begins to shape the way the parents view the baby.

You’d think that figuring out the gender would be simple, and it usually is, but once in my career I delivered a baby and could not tell whether it was a boy or a girl. I said nothing about the gender and the tension and distress of the parents were palpable.

The baby was born with a condition known as ambiguous genitalia. It’s just what it sounds like: external genitals that appear to be a cross between male and female. How does it happen?

For the first 7 weeks of development, every embryo appears to be female. In the absence of male hormones like testosterone, the baby will continue to have female external genitals. In boys, the testicles begin producing male hormones and the external genitals undergo further development. The clitoris enlarges into the penis, and the labia fuse together in the middle to become the scrotum.

It is possible for a baby to be a true hermaphrodite, having both ovaries and testes, but that condition is very rare. Ambiguous genitalia are usually caused by an inherited hormone problem that interferes with the development of the genitals. The baby is either a boy or a girl because it has either testes or ovaries, but the external genitals look like a combination of both, making it difficult to identify the gender simply by looking.

I had never seen a case of ambiguous genitalia before that night, but like every obstetrician I had read about it. And one of the things that I had read was that if there was any doubt about the gender, the doctor should not attempt to guess. According to a variety of studies, more psychological damage could be done by the doctor wrongly assigning gender and then having to change it, than by admitting that you didn’t know and consulting an expert to make the diagnosis.

Talk about an awkward situation! As the baby’s shoulders were being born I started to call out, “It’s a …” and stopped. I was stunned into silence. The baby appeared to be a girl with a very enlarged clitoris that looked like a penis, but I wasn’t sure. Mindful of what I had read, I didn’t want to guess. I asked the nurse to call the neonatologist to the room and I showed the baby to the parents. Not surprisingly, they were even more stunned than I was. I pointed out that the baby was healthy, with all other body parts intact, and I explained that the baby almost certainly had a treatable hormone problem, but the parents were distraught.

The neonatologist arrived within minutes and carefully examined the baby. He announced that the baby was a girl and that a treatable hormone problem had cause virilization (male appearance) of the external genitals. Ultimately the baby was diagnosed with congenital adrenal hyperplasia (CAH) the most common cause of ambiguous genitalia. CAH has effects in addition to ambiguous genitalia. It also leads to serious kidney problems, so it is very important that it be diagnosed and treated immediately.

After some time with mom and dad, the baby went to the newborn intensive care unit for a complete evaluation. Replacement of the appropriate hormones was started, and because the virilization of the genitals was mild, no surgical treatment was needed. The clitoris shrunk back to normal size and the baby did very well.

The parents, on the other hand, took a little longer to recover. The entire experience was deeply disturbing to them as it would be to any parents. And I never forgot it.

“Listen to your patient, he is telling you the diagnosis.”

Those are the words of William Osler (1849-1919) often called the Father of Modern Medicine for his contributions to the development of medical education. I first heard them from the chief of surgery at the beginning of my internship. It is almost always true, the patient is almost always telling you the diagnosis, but listening is harder than you might think. That’s because most patients are simultaneously offering a lot of extraneous information, and some patients are not completely honest in the information they offer.

In fact, the patients who are deliberately deceptive seem to have an outsize influence on the practice of medicine. During internship and residency, young doctors are repeatedly fooled, and therefore embarrassed, by patients. Drug addicts are notorious for presenting themselves as model citizens with serious pain problems. After several episodes of unwittingly giving an addict a fix, or a prescription for drugs that will be sold, young doctors begin to listen to a patients’ stories with increasing cynicism. The subtext for many physicians, consciously or unconsciously, is that they must be convinced that the patient is telling the truth.

I suspect that this problem is at the root of many errors of diagnosis. It is obviously much more difficult to diagnose a problem if the patient has an unusually constellation of symptoms. However, the biggest stumbling block is that the doctor believes that if the symptoms make no sense, the patient must be telling the story wrong, or have some other reason for the symptoms such as depression or medication seeking behavior.

That’s the biggest advantage I have when approached by a friend or relative for help with a difficult medical problem. It can sometimes be much easier for me to figure out the diagnosis than it is for the doctor they are seeing. That’s because I start out by believing them, because I know them, and I don’t waste valuable time pondering whether they are honest or reliable reporters of their symptoms.

Recently a friend called me about unusual symptoms his father-in-law was having. The relationship between our families has extended through several generations, and I knew his father-in-law well. He is a distinguished emeritus professor with a piercing intellect and ongoing curiosity and engagement with the academic world. As he approached and passed his 80th birthday, he was afflicted with slowly progressive muscle weakness. He became wheelchair bound and continued to weaken even further. Ultimately, he was barely able to muster the energy to move.

His impressive team of doctors was stymied by the symptoms and took the easy road. They concluded that he was weak because he was old. There was nothing to be done.

His son-in-law called because his children were convinced that something was going on besides normal aging, but did not know what tests and investigations to insist upon. That’s where my advantage came in. I listened to his story and believed him because I knew him and I knew them. I started from the premise that the story must be true and went from there.

Whenever an elderly person develops a global symptom like fatigue or confusion, the first place to look is at their medications. As people become older, they are put on ever increasing numbers of medications to treat various unrelated ills. Often, some of those medications will interact to produce unusual side effects. In addition, as people age, the ability of the kidneys or liver to break down the medication and remove it from the body diminishes. Because the medication stays in the body longer, it has a chance to build up to toxic amounts. A dose of medication that was conservative 10 years before may have slowly become an overdose.

Since whole body muscle weakness is certainly a global symptom, I asked for a list of his medications, and then I went down the list looking for generalized muscle weakness as a rare side effect. I hit the jackpot almost immediately. Pravachol, a statin (cholesterol lowering drug) he had been taking for decades, is known to cause generalized muscle weakness in rare circumstances by damaging muscle cells. The chance of this unusual side effect is increased in the elderly and is further increased in people with diminished kidney function, which happened to be present in this case as well.

I was so excited that I called my friend right away to tell him. I promised to do further research later in the evening, but in the meantime, he started investigating the rest of the list for unusual interactions between drugs. Sure enough, he found that another medication on the list was known to interact with Pravachol to increase the risk of generalized muscle weakness.

We had the diagnosis: Pravachol induced myopathy exacerbated by age, decreased kidney function and interaction with another drug. My friend called his father-in-law’s doctors first thing the next morning, and the Pravachol was discontinued. Recovery began almost immediately. He now feels better than he has in years and has begun to walk again.

The professor called me recently to express his gratitude. He thought I had made an incredible diagnosis. Frankly, I am a bit embarrassed. I didn’t really diagnose anything. He had been recounting the symptoms of statin induced myopathy in detail for months, if not years. All I did was listen.

Can women be trusted to make decisions about their own bodies?

In a previous post, I discussed the rising popularity of genital cosmetic surgery (Extreme Makeover: Vagina Edition). While the concept has been warmly embraced by women, it has elicited reactions ranging from distaste to outrage by others.

Everyone agrees that vaginal and vulvar cosmetic surgery has no medical benefit. Everyone agrees that views of genital attractiveness are strongly influenced by the prevailing culture. The point on which people disagree is whether women can be trusted to make decisions about their own bodies. Reactions range from paternalism and maternalism to acknowledging the possibility of autonomous decision making.

Paternalism is best exemplified by Daniel Sokol, writing in the British Medical Journal. According to Sokol:

The 16th century French author and physician Rabelais was obsessed with vaginas. In one of his stories an old lady drives the devil away by showing him her vagina. Today the devil might recommend she go to the nearest aesthetic surgeon for vaginal rejuvenation. A touch off the labia (labioplasty), a bit of tightening here (vaginoplasty), and voilà: a designer vagina…

Here is my paternalistic view: medical professionals, whether working in the private or public sector, should not succumb to these requests. Although it would be hard to argue that anyone seeking aesthetic genital surgery is unable to make an informed decision, it is plausible to argue that patients’ autonomy is often diminished by strong social or peer pressures.

Sokol at least is honest about his paternalism. Feminists who oppose genital cosmetic surgery seem to be entirely unaware of their maternalism. Their alarm shades into, dare I say it, hysteria. Bonnie Zylbergold asks whether genital “beautification” is plastic surgery or mutilation.

… Dr. [Lenore] Tiefer maintains that … all [genital cosmetic surgery] really produces is a generic model of women’s genitalia… So enraged is Dr. Tiefer, that in 2000 she founded The New View Campaign, an organization devoted to stopping all form of FGCS. The group compares FGCS to Female Genital Mutilation (FGM).

… [P]oints out Dr. [Virginia] Braun, “In both cases, what’s being done is that women’s genitalia are being altered to conform to a certain set of notions and expectations about what genitalia should look like, what they need to look like if they are to be appropriately feminine and appropriately desirable.”

Genital modification may be unnecessary, potential harmful, and the result of peer and marketing pressure, but it is not mutilation. And the claim that female genital mutilation represents a notion of genitalia “beauty” completely misrepresents the procedure. Genital mutilation is performed specifically to deprive women of sexual pleasure in an effort to ensure chastity. In other words, FGM is meant to prevent women from engaging in sexual intercourse, while vaginal cosmetic surgery is meant to enhance a woman’s opportunities for sexual intercourse.

The paternalists and maternalists agree on one fundamental point: women cannot be trusted to make decisions about their own bodies. Individual physicians must refuse to honor their wishes; regulatory agencies must make it impermissible for women to choose genital cosmetic surgery.

It is interesting to note that no one seems to think that men are incapable of making decisions about genital modification. Procedures to lengthen genitalia, prolong erection and otherwise enhance sexual “attractiveness” are equally if not more common among men, yet neither the paternalists nor the maternalists suggest that men must be restrained by their physicians or governmental regulations from making independent choices.

As distasteful as female genital cosmetic surgery may be to its critics, they are wrong to assume that women (and only women) should not be allowed to make these decisions. Rather, the principles that apply to all medical decisions should be invoked. Dr. Michael Goodman, writing in the journal Obstetrics and Gynecology explains:

Patients must be adequately screened, taking note of the ethical principles of autonomy, nonmaleficence, beneficence, justice, and veracity. Patients should be adequately protected and guided to develop reasonable expectations and understand that their genitalia are not abnormal. Surgeons should be adequately trained and experienced and should use universally accepted, accurate, and descriptive terminology. The procedures should be adequately described to patients, and risks and expected outcomes should be fully explained.

Genital cosmetic surgery, like all cosmetic surgery, has no medical benefits, substantial risk of harm and is often undertaken in response to cultural pressure. Nonetheless, informed consenting adults have a right to choose genital cosmetic surgery, just as they have the right to choose any cosmetic surgery.

I left clinical medicine for many reasons, but one of the most important is that caring for patients had become an endless slog of fighting administrators and other doctors. What did we fight about? Money, of course. Administrators did not want to spend it, and doctors did not want to risk doing work for which they might not be paid. I was afraid that one day, because I wasn’t up for a fight, one of my patients would be hurt. I had an experience shortly before I left practice that crystallized those fears.

A young woman who was 6 months pregnant called me one night when I was at the hospital. She had had pain in her leg for the past 2 days and the pain was getting worse. It wasn’t just that the pain was stronger; she had noticed that the pain appeared to be extending up her leg. First only the inside of her calf hurt, now the inside of her calf and her thigh hurt. I told her that she needed to come to the hospital because I was concerned that she might have a blood clot in her leg.

Blood clots in the leg (deep venous thrombosis or DVT) are potentially quite dangerous, and known to be more common in pregnancy. The danger of a DVT is that a piece of the clot in the leg can break off and travel to the lungs where it can cause death.

She arrived around midnight and I went to examine her. There are 5 classic signs of DVT and she had none of them. Her leg was not swollen, she had no tenderness over a major vein, the affected leg was not warmer, the skin over the vein was not discolored, and moving her foot in the prescribed way did not produce the pain typically associated with a DVT. Nonetheless, I had a bad feeling about this woman, and, over the years, I had learned to pay attention to bad feelings.

I explained to the patient that she had none of the signs of a DVT, but I was still worried. I wanted to get an ultrasound study of her leg to be absolutely certain that there was no blood clot. I apologized in advance, since it was unlikely that she had a blood clot, but blood clots are very dangerous and I wanted to be sure. The patient understood and agreed.

I called the radiologist on call and explained the story. I was very careful to point out that the patient had none of the classic signs of DVT, but I wanted the study anyway.

“No,” he said.

“Excuse me,” I replied. “I think I didn’t hear you correctly.”

“No,” he repeated. “I’m not going to scan her leg because she has none of the classic signs of a DVT.”

“Yes,” I said, somewhat exasperated. “I’m aware of that. I just told YOU that she has none of the classic signs, but I wanted to make sure.”

“Well, I’m not doing it because I won’t get paid.” He continued, “A scan in the middle of the night is an emergency and the insurance company will not pay for the scan unless it meets the criteria for an emergency scan. She must have some of those signs of a DVT or they won’t pay.”

We argued back and forth for a while, but he would not budge.

“Okay,” I said. “Just spell your name for me.”

He was puzzled. “Why do you need to know how my name is spelled?”

“Why? Because I am writing at the top of the very first page of the chart.” I cheerfully replied. “That way, when she walks out of the hospital and drops dead, they’ll know just whom they should sue.”

Silence.

“Well, if you’re going to be THAT way about it, I’ll scan her leg,” he said, “but I’m not going to do it right away.”

“Suit yourself,” I replied. “Just scan her leg before the morning.”

That exchange took place at 1 AM. I told the patient that we would have to wait for the scan, and I went to lie down.

At 5 AM my phone rang. The same radiologist was on the line, but now he sounded rather meek.

“Dr. Tuteur? Dr. Tuteur, I just wanted you to know that she has a blood clot in her leg extending from her ankle, up through her calf and thigh, right into her pelvis.”

Not only did she have a DVT, but she had the worst one either of us had ever seen. She almost certainly would have died from a pulmonary embolus if we had sent her home. Instead we immediately began treating her with blood thinners. She stayed in the hospital for two weeks, went home having learned to give herself shots of blood thinner, and ultimately did great. She delivered a healthy baby and had no further problem with blood clots.

Nonetheless, I was shaken up by the experience. She had only gotten the appropriate treatment because I had been willing to fight with the radiologist. In some ways, it had been a matter of luck. I wasn’t busy with other things; the radiologist had aggravated me, and was determined to prevail. I was uncomfortably aware that had circumstances been different, I might have failed to force the issue, and the patient would probably have died.

Why did the radiologist refuse to do the scan? He was simply responding to the incentives and punishments put in place by the insurance company. They didn’t want to pay for emergency scans so they made the requirements onerous. The insurance company was not wrong in assuming that patients without classic signs of DVT probably don’t have one, and they didn’t want to pay for needless scans. The radiologist was not wrong in assuming that this patient didn’t have a DVT and in assuming further that if he did the scan he would not be paid for it.

Almost everyone who has health insurance has fought with the insurer at some point because the insurance company has refused to pay. If you’ve done so know you just how frustrating that can be and how much time it takes. Doctors fight with insurance companies all the time, both to get approval for tests and procedures that patients need, and to get paid for visits, tests and procedures that have already occurred.

Most people don’t realize that doctors are often forced to fight with each other. The perverse incentives and punishments of the existing insurance system mean doctors who are trying to treat a patient must argue with other doctors who fear they will not be paid for their work. Sometimes, rather than fight to the bitter end, a doctor will give up and a patient won’t get a test or treatment that she needs. And sometimes, giving up could have fatal consequences.

I don’t do abortions.

I learned to do them, of course, as most gynecologists of my generation did, and I did them as part of my residency. That experience convinced me that abortions were not consistent with my view of providing patient care. I referred those of my patients who wanted abortions to other providers, and I never did another termination again.

Despite my personal views on abortion, I am horrified, appalled, and deeply outraged by the assassination of my colleague George Tiller. I am also profoundly humbled by his ultimate sacrifice. Tiller knew his life would probably end like this. He had already been shot, his clinic had been bombed, and he constantly received death threats. Yet none of that deterred him from standing for what he believed in.

It is a curious fact about conservative Republicans of this era, that they think the law applies to everyone but them. Abortion is legal, yet they try to interfere with it on a daily basis; legal access to abortion is the result of the political will, and is grounded in the American Constitution, yet conservative Republicans feel free to ignore the parts of the Constitution that don’t suit their prejudices; murder is the ultimate crime, yet they tacitly and actively encourage the murder of abortion providers. Many conservative Republicans feel that religion is so important that they attempt to defy the Constitutional separation of Church and State, yet they apparently have no problem violating the sanctity of a church to commit murder.

Terrorists always believe that the end justifies the means. Make no mistake about it; Operation Rescue and similar anti-abortion organizations are terrorist groups. They use the tactics of terror — harassment, threats, and violence — to impose their personal beliefs upon the rest of the country, which has explicitly rejected those beliefs. And while we’re being honest, let’s acknowledge that conservative Republican celebrities like Bill O’Reilly, tacitly encourage and support terrorism.

George Tiller was far braver than most of us could ever be. He believed that access to late term abortion is, in addition to a legal right, part of the reproductive freedom to which all women are entitled. He was willing to put his life on the line to defend that right, and he paid the ultimate price. He knowingly risked death to stand firm for his vision of healthcare. Who among us would be willing to risk so much for an abstract principle?

George Tiller was martyred by anti-abortionists, who, in addition to flouting the law, are foolish enough to believe that killing doctors will stop abortions. Of the million plus abortions performed in this country every year, almost all are first trimester or early second trimester abortions, and murdering Dr. Tiller will stop not a single one of those. Dr. Tiller was a specialist in late abortions, but there are other such specialists both here and in other countries. Anyone who had the means to get to Dr. Tiller has the means to get to the other providers.

What have the anti-abortion terrorists accomplished? They have revealed themselves as the terrorists they are. They have aroused the horror and support of Americans who might otherwise have little concern about abortion rights. They have strengthening the cause of abortion rights in this country. In other words, anti-abortion terrorists have accomplished absolutely nothing, except the senseless murder of a good man.

Good news, moms and dads! Your teenage daughters are using their budding entrepreneurial skills to become … prostitutes. That’s what Canadian film maker Sharlene Azam alleges in a new documentary and companion book called Oral Sex Is The New Goodnight Kiss.

According to the website:

…Attractive, white, high school girls – 13, 14 and 15 years old – are having sex with up to 7 men a night, several times a week, so they can go shopping. Other girls are selling their virginity for $1000. These are not street prostitutes. “They are the prettiest girls from the most successful families,” explains one expert…

The voices of the girls are cold enough to chill the hearts of the most jaded parent:

“Five minutes and I got $100,” one girl said. “If I’m going to sleep with them, anyway, because they’re good-looking, might as well get paid for it, right?”

“I’d begun having threesomes at a really young age. I did it for attention or because that guy has a connection to get you something that you want — drugs, clothes, whatever.”

Azam believes the phenomenon is new and places the blame squarely on the usual suspects.

The Internet:

Fifteen years ago, if a girl wanted to learn more about horses, she would go to the library and find pictures of horses in meadows. Today, if you type “horse” and “girl” in Google, the first hit is: “American girl licks hung horse dick”.

Celebrity Culture:

…Anyone who has ever stood in a supermarket checkout line knows that, in addition to conforming to an extremely narrow definition of beauty … today’s female pop icons are sex objects to be alternately exalted, ogled, emulated, critiqued, condemned, pitied, and recycled … ad nauseum…

With role models like these, immersed in a culture where sexuality is tied to celebrity status and money, girls are conditioned to feel empowered whenever they are the sexual center of attention.

Television:

Your daughter who may not yet have kissed a boy has probably seen a threesome, girl on girl kissing … and alcohol and drug use on Gossip Girl where there are no consequences and no interference…

But in reality, while the medium may be new, the message is as old as time. Women exist for the use and gratification of men, and have no worth of their own. These supposedly new sexual phenomena are the direct result of ancient beliefs: men are superior to women, women (their property and their bodies) are owned by men, the primary purpose of women is the sexual satisfaction of men.

These teenage Canadian prostitutes, for that is what they are, are the direct lineal descendants of royal mistresses, courtesans, and denizens of the “casting couch.” They sleep their way to what they want, because it is the easiest, quickest way to get what they want. Men are willing to pay for sex and the girls believe that they are exploiting that willingness.

These girls don’t realize that they are the ones being exploited. They sell themselves too cheaply, willing to trade their bodies for trinkets or a bit of discretionary income. This is not about sex, though sex is the medium of exchange. It’s about the dignity and worth of women.

Though they would no doubt balk at the comparison, these girls are no different than their sisters of 500 or 2,000 or 5,000 years ago. They are treated as, and believe themselves to be, nothing more than commodities. They accept that anything valuable in life can be gained only by pleasing men. They assume that women are not entitled to satisfaction during sex; that’s the province of men and women must be paid for their participation.

The solution to this problem is not keeping girls away from the Internet, TV and the celebrity culture. The solution is imbuing girls AND boys, women AND men, with the principle that women are independent moral beings, worthy of respect in their own right, and not objects of amusement for men. The solution is inculcating our daughters with the self confidence to achieve their desires through their own abilities, the self respect to scorn the advances of those who wish only to exploit them, and the sense of self worth that would prevent them from trading so much for so very little.

Fathers are now such a fixture in delivery rooms, it is easy to forget that this is only a recent development, extending back less than 40 years. It is difficult to fathom why they were excluded, since their presence is so valuable. They can help in a myriad of practical ways, sponging a forehead, spooning ice chips, holding a leg during pushing. However, their primary contribution comes in emotional support. They don’t call it labor for nothing, and encouragement and comfort are invaluable during the hours that labor lasts.

No one would want to go back to the days when fathers were excluded from the births of their children, but every now and then, the father poses challenges to the mother or the staff. Some fathers are not supportive, or worse, hectoring their partners or ignoring them altogether. Some fathers are drunk, or stoned, or carrying a weapon. Then there are the more delicate cases. When water became part of pain relief in labor, fathers wanted to get into the shower or the tub to offer support. That’s fine, as long as they wear a bathing suit, but not everyone remembers to put one on.

It is also possible for a father to be too helpful. That’s what happened to one of my midwife colleagues.

I was sitting at the nurses’ station filling out paperwork when the midwife came out from the room where she had just finished a delivery. Ordinarily that would not be notable, but her face was a shade of bright red, signaling profound embarrassment.

“What happened to you?” I asked.

“You’re not going to believe this,” she replied.

After a long, but uncomplicated labor, with several hours of pushing, her patient had given birth to a healthy baby boy. There had been no episiotomy. The midwife simply needed to deliver the placenta and then she could leave the couple to enjoy their new baby. The placenta took a while to detach, but the midwife was very patient, and waited for the gush of blood that heralded the detachment. After almost 20 minutes, the gush of blood came and the placenta followed shortly thereafter. Unfortunately, the blood kept gushing.

The midwife palpated her patient’s uterus. As she suspected, it was not contracting firmly, probably because of the protracted labor, a risk factor for hemorrhage. She massaged the uterus, and asked for pitocin to be placed in the patient’s IV. Then, wishing to employ natural methods as well, she explained to the patient that putting the baby to her breast would stimulate the release of oxytocin (natural pitocin) that would help stop the bleeding.

As the mother put the baby to her breast, the father cheerfully offered: “I’ll help, too!”

Before the midwife could explain that that wouldn’t be necessary, the father was suckling his wife’s other breast.

The midwife was mortified.

“It’s fine now,” she pointed out. “The bleeding stopped after the uterine massage and the pitocin. You don’t need to continue; nothing more is needed.”

“Don’t worry,” the husband replied. “It’s no bother. I do this all the time anyway.”

The midwife withdrew, to handle her paperwork and her embarrassment.

Lactivism, natural childbirth, attachment parenting. There’s a new moralism that defines motherhood to promote the personal preferences of a select group of women, wealthy, white women from first world countries. Mothering is now measured by a set of socially sanctioned “performances” at purported critical moments. Rebecca Kukla, a feminist scholar, has written a fascinating article in the International Journal of Feminist Approaches to Bioethics entitled Measuring Motherhood examining the middle class penchant of evaluating other women’s mothering by signal moments.

As a culture, we have a tendency to measure motherhood in terms of a set of signal moments that have become the focus of special social attention and anxiety; we interpret these as emblematic summations of women’s mothering abilities. Women’s performances during these moments can seem to exhaust the story of mothering, and mothers often internalize these measures and evaluate their own mothering in terms of them. “Good” mothers are those who pass a series of tests — they bond properly during their routine ultrasound screening, they do not let a sip of alcohol cross their lips during pregnancy, they give birth vaginally without pain medication, they do not offer their child an artificial nipple during the first six months, they feed their children maximally nutritious meals with every bite, and so on…

In other words, mothering has been reduced to a set of achievement tests that can be that can be passed or failed. Among those achievement tests are birth and breastfeeding.

… [W]e have elevated the symbolic importance of birth to the point where it appears to serve as a make-or-break test of a woman’s mothering abilities. If she manages her birth “successfully,” making proper, risk-adverse, self-sacrificing choices, and maintaining both proper deference to doctors and control over her own body, then she proves her maternal bona fides and initiates a lifetime of proper mothering. If, on the other hand, she fails at these tasks during labor, she reveals herself as selfish or undisciplined and risks deforming her baby’s character, health, and emotional well-being, while putting her bond with her child in permanent jeopardy.

Yet these claims have no basis in fact:

…[R]eal risks and their sizes do not seem to be of interest to the lay critics of mothers’ birth choices, who appear quite content with hand-waving references to gains and harms… [I]t is hard not to conclude that the main normative standards at play are ideological, not medical: Our cultural insistence that women make “proper” birth choices and maintain control over their birth narratives is not about minimizing real risks; rather, it supports our desire to measure mothering in terms of women’s personal choices and of self-discipline exercised during signal moments. What is at stake is not the health of babies but an image of proper motherhood, combined with the idea that birth should function as a symbolic spectacle of such motherhood.

Lactivists also make claims that have no basis in scientific fact:

North American breast-feeding promotional materials consistently emphasize exclusive breast-feeding, as opposed to the more productive message that the more breast milk babies receive, the better. “Does one bottle of formula make that much difference? We wish we could say that it doesn’t,” states La Leche League, rather disingenuously, in their breast-feeding guide, “but we can’t”. According to this guide, a single bottle of formula can trigger life-threatening allergies, and any contact with artificial nipples (bottles or pacifiers) can cause nipple confusion, wherein the baby is no longer willing or able to latch onto a breast… there is no evidence for nipple confusion resulting from the occasional use of artificial nipples. A 1992 study found no difference in breast-feeding outcomes between newborn infants who were exclusively breast-fed and those who received one bottle daily. The pervasive fear of instant nipple confusion among new mothers … is itself indicative of the power of the logic of the single corrupting moment.

It is hardly a coincidence that these claims reflect the personal preferences of a small group of Western, white women who are relatively well off.

Thus to the extent that we take “proper” maternal performance during these key moments as a measure of mothering as a whole, we will re-inscribe social privilege. We will read a deficient maternal character into the bodies and actions of underprivileged and socially marginalized women, whereas privileged women with socially normative home and work lives will tend to serve as our models of proper maternal character.

The bottom line is that a small group of privileged women hold their own choices choices regarding birth and infant feeding up as standards to which all women should aspire. This is wrong on several levels: there is no objective evidence that the claims of “natural” childbirth advocates and lactivists are true; there is no objective evidence that single moments of motherhood determine the long term well being of a child or determine the strength of the mother-child bond; and insisting that the cultural rituals of a privileged group of women are the standards to which all other women should aspire reinforces existing cultural and economic prejudices.

Vaccine rejectionists, when confronted with scientific evidence that does not support their claims, insist that their observations and beliefs are more reliable and more important than scientific evidence. They insist that their “intuition” about what happened when their children received vaccinations (they immediately developed autism, for example) is enough to “prove” that vaccines cause autism.

Vaccine rejectionists, like most believers in complementary and alternative medicine (CAM), place a great deal of emphasis on intuition. Partly, this is just magical thinking, the fervent belief that wishing can make it so. However, it also serves as an important justification for ignorance.

In Alternative medicine: A psychological perspective, Finnish scientists Marieke Saher and Marjaana Lindeman explore the reliance on intuition in “alternative” health. First the authors describe the difference in the two thinking styles:

… [I]ntuitive thinking is described as an unconscious, fast and effortless style of thinking, making use of such information sources as personal experiences, feelings, concrete images and narratives. Because the information processing is emotional as well as mostly unconscious, intuitive judgments are slow to change. … [R]ational thinking is characterised by conscious reasoning and mental effort, using all available objective information to come to a true answer, and willingness to adjust conclusions in the light of new facts.

The opposite of intuition is rational thinking. Vaccine rejectionists, like most advocates of “alternative” health, lack the knowledge base to think analytically about health and disease. They suffer from a fundamental lack of knowledge of science, the scientific method and statistics, not to mention a lack of basic knowledge of immunology and virology. Because they cannot participate in a meaningful way in rational scientific discussions, they self-servingly discount the value of rational thinking, and substitute intuition in its place. The “beauty” of intuition in healthcare is that it allows lay people to believe that they are “experts” in their own health and that they do not need doctors, or other rational thinkers, to advise them.

According to Saher and Lindemann:

… CAM messages favour familiar concepts (“naturalness”), similarity, personal experience and testimonials over abstract concepts like general principles and probabilities … Moreover, since CAM appeals to an intuitive thinking style, it may be especially attractive to people with a preference for this type of information processing.

… CAM beliefs and its use are not explained, predicted, or influenced by rational thinking and rational health information. Scientific information, which is central to the distinction between conventional and alternative medicine, involves numerical risk information and outcome statistics. Analysis of such material requires rational thinking … Although delivering rational health information will logically lead to an increase in rational health knowledge, it is likely to co-exist with intuitive knowledge rather than replace it. Actually, the ‘alternative’ status of CAM treatments alone is a rational message that they are not supported by science. Rationally spoken this can be interpreted as a warning, but for many CAM advocates it seems to come closer to an asset.

Reliance on intuition represents continuity with a pre-rational view of health and illness. Intuition is a more palatable name for the combination of ignorance, superstition and magical thinking that characterized healing among ancient and medieval peoples. The parallel can be extended further. In this model, “alternative” health practitioners are the modern day equivalent of shamans. Instead of offering rational prescriptions for health, they offer superstitions, affirmations, and support in rejecting rationality. Like shamans, they offer substances with no efficacy (herbs, homeopathy) and provide friendship and companionship as a substitute for knowledge.

The reliance on intuition is a central defect in vaccine rejectionism. It signals, it the clearest possible way, a rejection of rational thinking, knowledge and statistics. Ultimately, it is nothing more than a justification of ignorance.