Re: EFM
From: art fougner, md (evsono@pipeline.com)
Mon Jul 16 10:42:08 2007
EFM is possibly the single best argument FOR evidence-based medicine in
Obstetrics.
Art
At Mon, 16 Jul 2007, Joe wrote:
>
>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
>>>>
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>>>>
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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
>>>
--
art fougner, md
"May The Wings of Liberty Never Lose a Feather." - Jack Burton
