Midwife vs Doctor an ancient battle

I know that I’m probably kicking the proverbial hornets’ nest here, but after this mornings’ Twitter discussions, I think it is time that we start talking about this issue.

I have been a procedural GP Obstetrician for 20 years and have often clashed with my Midwife colleagues about certain issues and decisions.  We need to realize that doctors and midwifes are a bit like men and women, one is from Venus, the other from Mars.  We have quite different perspectives and point of views when it comes to antenatal, intra- partum and post natal care and these differences can and often do lead to some serious finger pointing between the “planets”.

It is important to remember however, that we all have the same end point in mind and that is the safety of our patients and in this case, the safety of both mother and baby.

There are a few important points to make here.

1.   Patient confusion.

Our difference in opinion on certain issues can and often do lead to patient confusion and may lead a patient to not discuss certain issues with either party.  This makes a very difficult time even harder and I do think has been of the major causative factor in the massive increase in cases of post natal depression.

2.   Responsibility.

Who is responsible for what and who gets to make the decisions?  As doctors we often feel that this is our privilege as we are ultimately the responsible persons and certainly will be the ones held responsible should anything go wrong.  This is not true.  The decision should ultimately be the patients’ and we as doctors and midwifes should make sure that our patients are fully informed about their decisions, but we can not and should not decide for them and should respect their decisions even if it is not what we believe.

3.   Accountability.

Here is a “biggie”.  Up to now, the doctor has been held responsible for everything and his insurer has been the first port of call for many a compensation lawyer.  I do think that with shared responsibility, comes shared accountability and that should include decisions made by fully informed patients.

So what is the solution to the problem.  Well, for starters, there are no problems, just a difference in opinion on many topics during the antenatal, intra-partum and post natal periods and the management of these issues.  We all need to respect these differences and not allow our own view on them to influence, change or confuse our patients in there own decision making process.  I do however think there need to be urgent regulation of private midwifery practices, who often exploit their unique relationship with their patients, to influence their decision making.  The regulation of these practices should be a collaboration between the RANZCOG and the ANC.

In the end of the day it is all about the health and safety of mother and baby and the respect of choice.


The Plight of Rural Healthcare

This mornings’ discussion on Twitter in support of Telederm, made me think about the difficulties faced by our rural communities especially when it comes to healthcare funding.  Having spend the majority of my career in rural and remote placings, I think I have a reasonable handle on the concept and can comment with some authority.

I think that one of the biggest problems facing healthcare provision in the bush, is the ever increasing idea of centralization of services.  NSW was the first state to embrace this new-found idea and we saw local board-run hospitals amalgamated into ever increasing Health Care Services and in the end have a service covering an area twice the size of Belgium.  This has since happened in most other states too and my most recent experience was in country South Australia with the “worst-of-them-all” health service, Country Health SA (CHSA).

Here is a health service, with it’s head office in Adelaide, and officials that can not pinpoint most of the town that fall under them on a map.  The problem with these massive health services is that they have no concept of what is happening on the ground, yet they try to employ a blanket ruling on how healthcare should be provided throughout.  The other problem, and maybe this is the “biggie” is that they just don’t care.  As long as there are adequate funds being pumped into the large cities, the powers-that-be care very little about what happens in the bush.

For 13 months, I worked in the small town of Penola, 50km from Mt Gambier, in the beautiful Coonawarra region of SA.  I was the only doctor in town and looked after the small hospital, an ED, two age care facilities with 36 beds (18 high and 18 low care beds) and a busy GP practice.  I worked 5 days a week and some days saw up to 60 patients a day and was on call every day, 24hrs a day, 7 days a week.  I was also expected to stay within 30min radius of the hospital, which in effect meant that I could go nowhere.  Now I have asked CHSA on a number of occasions for some time off.  There answer was that I can have time off only if I arrange locum cover and only if I give them 3 months’ notice.  This while interns and registrars fall over each others’ feet in Mt Gambier.

The bed in the ED was a modified trolley and by no means a “crash-bed” which made the few resuscitations I had to do very challenging.  I have brought this under the attention of CHSA on a number of occasions and their answer was that there was no money in the budget.  Yet they approved a $12mil upgrade of the Mt Gambier ED.

As rural communities, we are bottom-feeders and seen to be lucky to get anything at all.  Our patients are the ones that have to travel hundreds of kilometers to see a specialist and wait months before doing so, just to be told by the registrar to come back next week to check your dressing; yes sure, it’s only 400km away.

And why are we accepting this?  Well, we are not, but our voices does not get heard, because most of the rural areas are in what the Pollies call “safe seats” thus making any fuss about it, a waste of their precious time.  Healthcare, along with education, welfare and now the NBN, has become a political carrot which the Pollies can hang in front of the voters’ noses.  When it comes to delivering on these promises, the carrot is usually nowhere to be found or at the post long eaten by the city dwellers.

What is the answer?  Well for a start give the control back to the local communities who know what their community needs and then fund them well.  I’ll use the Penola model again as an example.  In the days when the hospital was board run, the hospital board were made up of volunteers, local business people who donated there time and effort in support of the local community.  The day to day administrative management was done by 1 administrative officer.  The “matron” or in today’s terms, Nurse-manager was also on the ward, working as one of the clinical staff.  Said admin officer had a salary of $50K (approx).  Back then it should be said that the activity of the hospital was also far more, with surgery done, deliveries and even local radiology.  Today, with things run by CHSA, the admin staff at the hospital is 8 with a combined annual salary of $500K (approx).  This while the activity has dropped to basically being an age care facility with a small ED attached.  How does that make economic sense?

So next time you ask yourself where has all the funding gone?  Try looking in the pockets of the bureaucrats.

Should I or shouldn’t I…..

A recent story in the news and the discussions that followed between the Twitterati made me think; should we as doctors share our personal views and beliefs with our patients?  And would sharing these beliefs bring us closer or divide us?

The article in question was the one about a family GP who refused to refer a patient for a TOP because the wanted a boy and not a girl (it may have been the other way round, I have a short attention span) and now faces potential action from AHPRA.

As a Christian, I have certain views on TOP’s and have often shared these with my patients.  I have however, never allowed these beliefs to challenge my patients decision.  Should I?

At church we are working through a study course called “Not a fan” which challenges us with the question whether we are “fans” or “followers” of Jesus, with the difference between the two, the level of personal commitment.  One of the very challenging questions this week was “…when last did following Jesus cost you anything and what was that cost…?”.

Now that brings me back to the question, if I say that I am a truly committed Christian, should my beliefs not dictate my actions even if that costs me a reprimand from AHPRA?  How many times do we as doctors simply keep quite about issues just because we are governed by some form of ethic bureaucracy?  I can certainly think of a number of very current issues in my practice:

  1. The 14yr old coming in with her mother and asking for oral contraception.
  2. The husband returning from his “business trip” in Asia with a STI.
  3. Termination of pregnancy.
  4. Etc.

Now I am not saying for one moment that everyone should have the same beliefs, the question I ask is this:  How often do we as doctors keep quite about an issue simply because a patient has rights and we are fearful of potential repercussions through litigation or regulating authorities?

Let me know what you think.