Re: EFM
From: Joe (forcep@intercom.net)
Mon Jul 16 06:20:52 2007
DP: The "expert" interpretation of EFM caused my demise from obstetrics.
The intellectual "lag" exhibited by ACOG and our fellow obstetricians in
recognizing your well spoken point is probably the biggest black mark on
us as a profession ever. Joe C
David Priver wrote:
> This has been a truly fascinating thread at so many levels, especially
> chain of command. What has not been addressed is the phenomenon which
> frequently occurs at every OB unit I've ever worked on and that is the
> tendency of labor nurses to literally freak out over the most minor of
> EFM events. The fact that a normal healthy baby was ultimately
> delivered here suggests that this was another one of these events. My
> suspicion is that these nurses are often sent to EFM courses, put on by
> the manufacturer of the monitors, at which EFM is purported to be a
> perfect diagnostic modality. Anyone who reads studies of EFM knows they
> are anything but.The accuracy of EFM at diagnosing a hypoxic fetus is
> dismally low. Any labor nurse who claims to be "certain" that a given
> pattern reflects a hypoxic fetus simply doesn't understand fetal
> monitoring. Our adoption of this modality as the final arbiter of fetal
> status is probably one of the main causes of the liability crisis we
> have faced over the last 30 years.
> DP
>
> At Fri, 13 Jul 2007, ainsron wrote:
>
>>The airline analogy does not address chain of command, but captain of the
>>ship. In years long past, nurses and technicians were too intimidated to
>>speak up when something was noted that was amiss - such as a missing sponge,
>>abnormal lab test, etc. The physician involved felt that anyone who speaks
>>up was challenging his authority and retaliated against his underlings. In
>>most hospitals now, any member of the healthcare team can identify a
>>possible area of trouble and address it with any other member without fear
>>of retribution, as they should be. I've always practiced in small hospitals
>>where the department chairman, chief of staff and other medical leaders were
>>volunteering their time and don't have the authority to supplant another
>>physician's judgment, unless there is a serious threat to life or limb. If
>>it evoked, it triggers a significant cascade of events by the staff bylaws,
>>including judicial review hearings, revocation of privileges, etc. and is
>>avoided under most circumstances.
>>
>>Ronald E. Ainsworth, MD, FACOG
>>
>>-----Original Message-----
>>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of D. Ashley
>>Hill
>>Sent: Thursday, July 12, 2007 9:07 PM
>>To: Multiple recipients of list OB-GYN-L
>>Subject: Re: EFM
>>
>>Thanks for the comments. Our department chairs have the authority to
>>suspend privileges instantly if there is concern about quality of care.
>>At that point they likely would delegate care to the on-call physician
>>or assume care themselves.
>>
>>I have seen a lot of interesting variations of the chain of command,
>
>>from disagreements about seemingly benign aspects of care (for example,
>
>>whether to give a medication BID or TID) to concern about shocking
>>deviations from universal standards of care. Interestinly, in almost
>>all cases, when the division or department chief reviews the case and
>>talks with the attending physician, he or she usually acquieses as if
>>"you caught me." I agree with others that every department needs a
>>formal chain of command with predetermined "rules of engagement."
>>
>>I have seen this concept presented analogous to the airline industry.
>>Many years ago the airline industry had a landmark accident (I can't
>>recall the details, but I think it involved ice on the wings) where
>>several flight attendants and others noticed a problem but either were
>>afraid to approach the captain or assumed he, being the boss, would
>>already know about the problem. In the healthcare industry the doctor
>>used to be king. It's safer to have everyone focusing on patient safety
>>first, without regard to physician ego. Thanks again.
>>
>>Ashley
>>
>>At Thu, 12 Jul 2007, William D. McIntosh, M.D wrote:
>>
>>>While your point is taken, and there is no doubt that there are a few
>>>bad docs making lots of bad decisions, and a lots of good docs making
>>>occasional bad decisions, I cannot see myself as Chief walking into a
>>>patient's room, a patient that I have never met, and declaring that
>>>because there is a REASONABLE difference of opinion on her management, I
>>>am terminating her care by her chosen physician, and substituting my own
>>>plan. There is neither legal nor moral authority for that in any
>>>hospital bylaws. Remember the case we are discussing, and that we are
>>>talking about a difference of opinion on management, not neglect or
>>>incompetence. Not the same thing at all. For what its worth, our
>>>bylaws here include no provision whatsoever for the Chief to wrest the
>>>control of a patient from the attending.
>>>
>>>As an aside, I am not criticizing the nurse pursuing this issue up the
>>>chain of command. That is what the chain is for, the protection of both
>>>the patient, and the concerned staffer. She did what she needed to do,
>>>but the fact that she complained does not make the charge proven, as Joe
>>>so eloquently noted.
>>>
>>>William D McIntosh, MD FACOG
>>>
>>>Clarksville, TN
>>>
>>>-----Original Message-----
>>>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of D.
>>>Ashley Hill
>>>Sent: Wednesday, July 11, 2007 9:40 PM
>>>To: Multiple recipients of list OB-GYN-L
>>>Subject: Re: EFM
>>>
>>>Many hospitals have bylaws that every physician on staff subscribes to
>>>
>>>as part of membership. These may include mandates that the chief of the
>>>
>>>department (and certainly the chief of staff) has the authority to
>>>
>>>override clinical decisions by the staff physician if the chief
>>>
>>>determines that care is not in the best interest of the patient.
>>>
>>>Hopefully hospitals have formal policies for this and structured
>>>
>>>committees to evaluate these types of complaints.
>>>
>>>Let me add another direction to this discussion. Over the years I have
>>>
>>>seen physicians (mostly at hospitals other than my own, but some here)
>>>
>>>try to put vacuums on breech or face presentations, try to induce 34
>>>
>>>week patients for no other reason than they were leaving town for
>>>
>>>vacation, and attempt to perform major surgical procedures that they did
>>>
>>>not have any training or privileges to perform (think breast
>>>
>>>augmentation). The chain of command worked in these (thankfully rare)
>>>
>>>situations and those physicians were both stopped from harming patients
>>>
>>>and provided with an impetus for remediation (get remediation or don't
>>>
>>>come back). Not all physicians are as skilled as or ethical as you are.
>>>
>>>I dispute your argument that there is no legal standing for the
>>>
>>>department or hospital chief to intervene in the care of your patient
>>>
>>>when he or she feels, after careful review, that your care endangers the
>>>
>>>patient. Likely, you signed something to that effect when you signed on
>>>
>>>for medical staff privileges. Best wishes,
>>>
>>>Ashley
>>>
>>>At Wed, 11 Jul 2007, William D. McIntosh, M.D wrote:
>>>
>>>>If the current Dept Chief wants to take over the management of one of
>>>
>>>my
>>>
>>>>patients without my permission, he had better bring a sack lunch and a
>>>
>>>>lot of help, because it is going to be a long, hard day. He has no
>>>
>>>>legal or professional standing to overrule my management as long as I
>>>
>>>am
>>>
>>>>physically and mentally competent. He might not like my plan, and my
>>>
>>>>privileges might be challenged later, but the relationship between my
>>>
>>>>patient and me is not open to review by my hospital. SHE can fire me,
>>>
>>>>or SHE can sue me, but the poor sod stuck with Dept Chair has no
>>>
>>>>jurisdiction over that relationship. Management might be open to
>>>
>>>>debate, but in the end, I would be the only doctor in the room with a
>>>
>>>>doctor-patient relationship (in both the legal and professional
>>>
>>>senses),
>>>
>>>>and that relationship can only be altered by the direct participants.
>>>
>>>>For that matter, if he were to touch the patient without her
>>>
>>>permission,
>>>
>>>>would that not constitute assault?
>>>
>>>>--
>>>
>>>>William D. McIntosh, MD, FACOG
>>>
>>>>Clarksville, TN
>>>
>>>>-----Original Message-----
>>>
>>>>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
>>>
>>>Robert
>>>
>>>>J. Carpenter, Jr. MD, JD
>>>
>>>>Sent: Tuesday, July 10, 2007 7:50 PM
>>>
>>>>To: Multiple recipients of list OB-GYN-L
>>>
>>>>Subject: Re: EFM
>>>
>>>>Given facts of the case, your responsibility as service chief is
>>>
>>>>evaluation of the nurse's
>>>
>>>>concern as chain of command decision-maker. If you agreed with the
>>>
>>>>nurse, then
>>>
>>>>discussion with the attending MD about your agreement is mandated.
>>>
>>>>If he did not agree to C/S, then you could/should take over management
>>>
>>>>after
>>>
>>>>discussion with the patient concerning the events, findings, and the
>>>
>>>>differences in
>>>
>>>>opinion. If you do not agree with the nurse then you have fulfilled
>>>
>>>your
>>>
>>>>duties and
>>>
>>>>continued management of the labor would be appropriate.
>>>
>>>>If following the delivery, the nurse's opinion is validated and
>>>
>>>>continued vaginal delivery
>>>
>>>>was allowed, then you may have to explain why you made the decision you
>>>
>>>>did and
>>>
>>>>failed to intervene. On the otherhand, if the baby is severely
>>>
>>>impaired,
>>>
>>>>you may have to
>>>
>>>>prove that the interval from your consultation to the penultimate
>>>
>>>>delivery, did not
>>>
>>>>change the outcome of the patient.
>>>
>>>>It is not an enviable situation to be in but been there, done that, and
>>>
>>>>I have both
>>>
>>>>intervened and continued current management. As Mr. Truman said: "The
>>>
>>>>buck stops
>>>
>>>>here." True for all of us in chain of command status.
>>>
>>>>Look fwd to the outcome
>>>
>>>>Robert J. Carpenter, Jr. MD, JD
>>>
>>>>6624 Fannin, #2720
>>>
>>>>Houston, TX 77030
>>>
>>>>(O) 713-795-4600
>>>
>>>>(F) 713-795-4422
>>>
>>>>"Life is difficult"
>>>
>>>>The Road Less Travelled
>>>
>>>>by Scott Peck
>>>
>>>>Premier Medical Group's HIPAA Compliance Policy states that unencrypted
>>>
>>>Protected Health Information (PHI) will not be sent to external email
>>>recipients. If this email contains PHI, please inform both the original
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>>>(securityofficer@premiermed.com or 931-245-7044) of this policy
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>>>
>>>--
>>>
>>>D. Ashley Hill, MD
>>>
>>>Associate Director
>>>
>>>Department of Obstetrics and Gynecology
>>>
>>>Florida Hospital Family Practice Residency
>>>
>>>Medical Director, Loch Haven Ob/Gyn Group
>>>
>>>Division Director, Dept. of Ob/Gyn, Florida Hospital Orlando
>>>
>>>Orlando, Florida
>>>our patients' personal information.
>>>
>>
>>--
>>D. Ashley Hill, MD
>>Associate Director
>>Department of Obstetrics and Gynecology
>>Florida Hospital Family Practice Residency
>>Medical Director, Loch Haven Ob/Gyn Group
>>Division Director, Dept. of Ob/Gyn, Florida Hospital Orlando
>>Orlando, Florida
>>
>
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