[med/anthro] Re Surgeons, 2
I'm not planning on critiquing or criticising surgery at all; I'm ultimately going somewhere completely else with this.
But as a side note, while I was writing, Would you consider that a fault with surgery as a medical practice, that needs to be remedied through better standarization and training?
I suddenly remembered something, from the aforementioned "The Score".
My readers may be intrigued to learn that there was another medical specialty that had exactly that reaction, concerning another highly invasive, high risk procedure - or class of procedures - that, as it happens, wasn't surgical.
It was obstetric.
Gawande's The Score (available free and in full at that link; and have I mentioned lately how it's one of the best things I've ever read?), subtitled, "How childbirth went industrial", covers many things, and one of them is the history of the use of forceps in complicated births. Forceps revolutionized maternal and fetal survival. And today, they are almost never used. What happened is extremely thought provoking: I spoke to Dr. Watson Bowes, Jr., an emeritus professor of obstetrics at the University of North Carolina and the author of a widely read textbook chapter on forceps technique. He started practicing in the nineteen-sixties, when fewer than five per cent of deliveries were by C-section and more than forty per cent were with forceps. Yes, he said, many studies did show fabulous results for forceps. But they only showed how well forceps deliveries could go in the hands of highly experienced obstetricians at large hospitals. Meanwhile, the profession was being held responsible for improving Apgar scores and mortality rates for new-borns everywhere-at hospitals small and large, with doctors of all levels of experience.
“Forceps deliveries are very difficult to teach-much more difficult than a C-section,” Bowes said. “With a C-section, you stand across from the learner. You can see exactly what the person is doing. You can say, ‘Not there. There.’ With the forceps, though, there is a feel that is very hard to teach.” Just putting the forceps on a baby’s head is tricky. You have to choose the right one for the shape of the mother’s pelvis and the size of the child’s head-and there are at least half a dozen types of forceps. You have to slide the blades symmetrically along the sides, travelling exactly in the space between the ears and the eyes and over the cheekbones. “For most residents, it took two or three years of training to get this consistently right,” he said. Then a doctor must apply forces of both traction and compression-pulling, his chapter explained, with an average of forty to seventy pounds of axial force and five pounds of fetal skull compression. “When you put tension on the forceps, you should have some sense that there is movement.” Too much force, and skin can tear, the skull can fracture, a fatal brain hemorrhage may result. “Some residents had a real feel for it,” Bowes said. “Others didn’t.”
The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills-the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands.
But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.
[...]
We have reached the point that, when there’s any question of delivery risk, the Cesarean is what clinicians turn to-it’s simply the most reliable option. If a mother is carrying a baby more than ten pounds in size, if she’s had a C-section before, if the baby is lying sideways or in a breech position, if she has twins, if any number of potentially difficult situations for delivery arise, the standard of care requires that a midwife or an obstetrician at least offer a Cesarean section. Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth.
I asked Dr. Bowes how he would have handled obstructed deliveries like Rourke’s back in the sixties. His first recourse, as you’d expect, would have included forceps. He had delivered more than a thousand babies with forceps, he said, with a rate of neonatal injury as good as or better than with Cesarean sections, and a far faster recovery for the mothers. Had Rourke been under his care, the odds are excellent that she could have delivered safely without surgery. But Bowes is a virtuoso of a difficult instrument. When the protocols of his profession changed, so did he. “As a professor, you have to be a role model. You don’t want to be the cowboy who goes in to do something that your residents are not going to be able to do,” he told me. “And there was always uncertainty.” Even he had to worry that, someday, his judgment and skill would fail him.
These were the rules of the factory floor. To discourage the inexpert from using forceps-along with all those eponymous maneuvers-obstetrics had to discourage everyone from using them. When Bowes finished his career, in 1999, he had a twenty-four-per-cent Cesarean rate, just like the rest of his colleagues. He has little doubt that he’d be approaching thirty per cent, like his colleagues today, if he were still practicing.
I don't offer this as a criticism or suggestion to anybody or for anything. Just thought it very interesting and thought provoking.
I'll get back to what I was doing in a moment.
But as a side note, while I was writing, Would you consider that a fault with surgery as a medical practice, that needs to be remedied through better standarization and training?
I suddenly remembered something, from the aforementioned "The Score".
My readers may be intrigued to learn that there was another medical specialty that had exactly that reaction, concerning another highly invasive, high risk procedure - or class of procedures - that, as it happens, wasn't surgical.
It was obstetric.
Gawande's The Score (available free and in full at that link; and have I mentioned lately how it's one of the best things I've ever read?), subtitled, "How childbirth went industrial", covers many things, and one of them is the history of the use of forceps in complicated births. Forceps revolutionized maternal and fetal survival. And today, they are almost never used. What happened is extremely thought provoking: I spoke to Dr. Watson Bowes, Jr., an emeritus professor of obstetrics at the University of North Carolina and the author of a widely read textbook chapter on forceps technique. He started practicing in the nineteen-sixties, when fewer than five per cent of deliveries were by C-section and more than forty per cent were with forceps. Yes, he said, many studies did show fabulous results for forceps. But they only showed how well forceps deliveries could go in the hands of highly experienced obstetricians at large hospitals. Meanwhile, the profession was being held responsible for improving Apgar scores and mortality rates for new-borns everywhere-at hospitals small and large, with doctors of all levels of experience.
“Forceps deliveries are very difficult to teach-much more difficult than a C-section,” Bowes said. “With a C-section, you stand across from the learner. You can see exactly what the person is doing. You can say, ‘Not there. There.’ With the forceps, though, there is a feel that is very hard to teach.” Just putting the forceps on a baby’s head is tricky. You have to choose the right one for the shape of the mother’s pelvis and the size of the child’s head-and there are at least half a dozen types of forceps. You have to slide the blades symmetrically along the sides, travelling exactly in the space between the ears and the eyes and over the cheekbones. “For most residents, it took two or three years of training to get this consistently right,” he said. Then a doctor must apply forces of both traction and compression-pulling, his chapter explained, with an average of forty to seventy pounds of axial force and five pounds of fetal skull compression. “When you put tension on the forceps, you should have some sense that there is movement.” Too much force, and skin can tear, the skull can fracture, a fatal brain hemorrhage may result. “Some residents had a real feel for it,” Bowes said. “Others didn’t.”
The question facing obstetrics was this: Is medicine a craft or an industry? If medicine is a craft, then you focus on teaching obstetricians to acquire a set of artisanal skills-the Woods corkscrew maneuver for the baby with a shoulder stuck, the Lovset maneuver for the breech baby, the feel of a forceps for a baby whose head is too big. You do research to find new techniques. You accept that things will not always work out in everyone’s hands.
But if medicine is an industry, responsible for the safest possible delivery of millions of babies each year, then the focus shifts. You seek reliability. You begin to wonder whether forty-two thousand obstetricians in the U.S. could really master all these techniques. You notice the steady reports of terrible forceps injuries to babies and mothers, despite the training that clinicians have received. After Apgar, obstetricians decided that they needed a simpler, more predictable way to intervene when a laboring mother ran into trouble. They found it in the Cesarean section.
[...]
We have reached the point that, when there’s any question of delivery risk, the Cesarean is what clinicians turn to-it’s simply the most reliable option. If a mother is carrying a baby more than ten pounds in size, if she’s had a C-section before, if the baby is lying sideways or in a breech position, if she has twins, if any number of potentially difficult situations for delivery arise, the standard of care requires that a midwife or an obstetrician at least offer a Cesarean section. Clinicians are increasingly reluctant to take a risk, however small, with natural childbirth.
I asked Dr. Bowes how he would have handled obstructed deliveries like Rourke’s back in the sixties. His first recourse, as you’d expect, would have included forceps. He had delivered more than a thousand babies with forceps, he said, with a rate of neonatal injury as good as or better than with Cesarean sections, and a far faster recovery for the mothers. Had Rourke been under his care, the odds are excellent that she could have delivered safely without surgery. But Bowes is a virtuoso of a difficult instrument. When the protocols of his profession changed, so did he. “As a professor, you have to be a role model. You don’t want to be the cowboy who goes in to do something that your residents are not going to be able to do,” he told me. “And there was always uncertainty.” Even he had to worry that, someday, his judgment and skill would fail him.
These were the rules of the factory floor. To discourage the inexpert from using forceps-along with all those eponymous maneuvers-obstetrics had to discourage everyone from using them. When Bowes finished his career, in 1999, he had a twenty-four-per-cent Cesarean rate, just like the rest of his colleagues. He has little doubt that he’d be approaching thirty per cent, like his colleagues today, if he were still practicing.
I don't offer this as a criticism or suggestion to anybody or for anything. Just thought it very interesting and thought provoking.
I'll get back to what I was doing in a moment.