Collateral Damage: A Patient’s Experience of Defensive Medicine
Something is rotten in the state of provider-patient relations in this country. And for many women, their first inkling of that fact occurs when they get pregnant.
Most people who have spent their lives relatively healthy are extremely trusting of their doctors. Why shouldn’t they be? Doctors work miracles and help us prolong our lives. And since the 1950s, there has scarcely been a television season that didn’t include a medical drama of some kind, always told from the practitioners’ point of view. “Bad” or abusive doctors were nonexistent, except as perhaps a Story of the Week or a Very Special Episode, and they always got their comeuppance (or even redemption).
If the hospital system itself came under critique, it was only because it was trying to prevent a heroic doctor from trying a risky procedure that Might Just Work, or because it was too beholden to the evil insurance companies who didn’t want to pay for little Timmy’s lifesaving liver transplant.
Why am I using pop-culture examples when I want to talk about actual patient experiences? Because these are the stories we as a society tell ourselves about doctors and medicine. They’re very nice stories. They make us feel good about having to go the hospital one day, where gruff but kind surgeons and sassy nurses will take care of us. They tell us doctors are amazing people who do what they do out of basic decency and a desire to help. And of course, many doctors are like that, or try to be.
But there is a problem with these stories, these scripts—mainly, that the patient herself is pushed into the role of extra. The patient is to be the quiet and cooperative plot device, lying in bed, smiling bravely around her respirator as she gratefully clutches the doctor’s hand. Whatever their personal quirks, in the end the patients, Do What They’re Told, even if it seems unnecessarily painful or contradictory, and that’s what saves their lives. (See: every episode of House).
Not being a conspiracy theorist, I don’t think TV’s portrayal of doctors as healing, sexy saints is part of a sinister plot. We like heroes, and the work doctors do is often heroic. But it would be surprising if all those hours of medical soap opera starring brilliant saviors didn’t have an effect on our expectations. When it becomes our turn to enter the drama, to seek help or healing, we find the role of compliant, grateful, passive patient familiar and easy to slip into.
And let’s be honest; things are much easier for the hospital when we do.
But what happens when we don’t? What happens when we challenge the doctor’s decision, disobey the nurse’s orders, educate ourselves and decide to try different approaches, or question interventions? What happens when we go off the script and start trying to make more decisions about our own treatment?
That’s usually when we find out that we are in hostile and unfamiliar territory.
When I was pregnant with my son, the nurse-midwife practice I picked used all the right words; natural birth, no rushing, no pushing drugs or c/sections. I had an uneventful pregnancy, and for the most part, the midwives I saw followed that model of care. Examinations were low-key. We talked about raspberry leaf tea and whether I should get a doula, an idea they supported. There was lots of smiling and congratulations on my health and my baby’s health.
There was one midwife I didn’t like as well, though. She had a habit, as my pregnancy progressed, of frowning and saying “Hmm” in a worried tone. (In fact, let’s call her Midwife Hmm). After each “Hmm” she’d say something like: “I hope you go into labor soon, because I wouldn’t want this baby to get too big,” or “This baby certainly is measuring large,” or “I wouldn’t want you to have a c/section.”
Let’s pause for a minute and review these statements. What, exactly, was their purpose?
Were they directions as to what I should do or not do? No. I had no control over my baby’s size or when I went into labor. She had also met my 6 foot 4 husband and presumably noticed that I was not a short woman. My blood sugar levels stayed, if anything, low. My blood pressure was excellent. I felt fine except for aches and pains, and the baby was firmly head down. I had no evident risk factors for a c/section.
So why the hmm-ing, the frowning, the general air of pessimism about my ability to give birth vaginally? I can think of no other reason than that she was, consciously or unconsciously, attempting to manipulate my expectations and provide cover for whatever interventions she or the OB might want to make.
After all “managing patient expectations” is part of practicing defensive medicine. It sets the tone of the discussion, defines what is and isn’t possible or likely.
I was taller and my baby larger than a lot of women. I was a first-time mom. I was pretty casual about her concerns and didn’t automatically panic at her head-shaking or hmm-ing. I was adamantly against early induction. I even talked back and told her I thought we really didn’t have anything to worry about. I was, in other words, not behaving compliantly, not having a reassuringly small baby and early labor, and therefore, a possible threat. And so she set about moving the goalposts and in the process, undermining my confidence.
It’s not like it was all that hard. Like any first-time mom, I was full of worries. Little by little, her negativity had the effect of isolating me and weakening me, psychologically. However casual I acted, it shook me that one of my own midwives did not think much of my chances of giving birth without interventions. And given that most of the people around me didn’t either (my family history was full of c/sections and twilight births) I began to feel more and more uncertain of myself.
All the same, I clung to one decision I had made; I was not going to be induced before the full 42 weeks was up and I’d given my son a chance to come out on his own. This eminently sensible idea was greeted by Midwife Hmm, and also, the clinic’s director, as risky and foolhardy—though as I later learned, it was actually just inconvenient to the hospital’s schedule (they preferred delivering on Thursdays to free up the weekend).
And, to everyone’s increasing disgruntlement but mine, my son seemed determined to wait his time out. Although every stress test came up beautifully and my son and I were fine, I soon had the feeling that I had been demoted from the Compliant Patient column to the Shit List. What’s funny is that, in a way, Midwife Hmm’s little psych-outs had backfired on this front; she’d made me so nervous about failing at labor that I was no longer eager to get started.
Nevertheless, I had agreed to be induced the first Monday of my 43rd week, and went to bed the night before D-Day without a detectable contraction. Then at 5am I woke up suddenly and my water broke, spectacularly and messily; I leapt out of bed like a startled but very pregnant deer and ran to the bathroom before my husband had cracked open his eyes. I was in labor! I was ecstatic. I was triumphant. I thought I had proved them wrong and that now, finally, they would see that I could do this and everything would be OK. I could just go to the hospital and have my baby.
But here’s the thing about being on the Shit List as a patient: it’s a permanent demotion. A little thing like a healthy pregnancy and spontaneous labor was not going to change my status as Problem Patient.
When I got to the hospital, I was told hospital policy was that I must be put on Pitocin because I was at 42 weeks. I assumed, though I was not actually told one way or another, that it was accept Pitocin or leave the hospital. With my water gushing between my legs, presumably.
I went quickly from triumphant to afraid. My birthing classes taught me a lot about squatting, but nothing about EMTALA, the law that protected me from being kicked out while I was in active labor, regardless of whether I was compliant or not. I had legal protections, but they had been hastily skimmed over and buried in the fine print, and no matter how good a weapon you have, it’s useless if you don’t know how to use it.
The grim faces, frowns, and even anger that confronted my timid request that I not be induced were very effective in the face of my ignorance. We didn’t have a car and had taken a taxi in to the hospital; now that I was in labor, I was terribly afraid of being forced to leave if I didn’t comply. I had visions of walking around the hospital parking lot shivering in the November wind and leaking amniotic fluid until it was time to push and they grudgingly let me back in. All the weeks of insecurity and anxiety, my resistance to the idea that a medical person would actually tell me to do something harmful, combined with the desire to stay in my nice warm hospital room, were too much for me. I caved. I let them hook up the Pitocin and hoped for the best.
I don’t know how high they turned it up, but the contractions became unbearable and fast a few hours later, a near-continuous ring of fire around my back and pelvis that had me climbing the walls. I was told I couldn’t remove the damned itching and beeping monitor, so I couldn’t use the shower for pain relief. I was told to stop leaning on the end of the bed, because it wasn’t sturdy enough, which left me to either stand up clutching the back of a chair or kneel on the cold, dirty floor, which I couldn’t make myself do. Random people came in to my room, entered data in a computer in the corner, and left, never talking to me. My husband was afraid. My doula was inexperienced. The birth ball did not help. The ice chips made me shiver and ache, but gave me no strength. I could not relax, and so the fear took over.
Finally, I took the epidural because it was the only way left to me to deal with the pain. And it worked, but the baby stalled. I fell into an exhausted doze on my bed, frightened and withdrawn.
I woke up to Midwife Hmm standing over me again, with her familiar frown. I was taking too long, she told me. We really needed to c/section if we wanted to avoid “risks.” Drugged, exhausted, and uncaring, I said yes.
An hour or so later I lay alone in the recovery room, deeply shaken by the surgery, my baby taken away screaming because they wouldn’t let him stay with me and breastfeed. As I lay there stunned and trembling, I believed that, just as Midwife Hmm had hinted, what had happened was all my fault. I was weak and my body was broken and vaginal birth was just not going to happen for me. I’d clearly been foolish to even try it. To think someone faulty like me could do something extraordinary like that.
I’d lost the battle, and I’d lost big.
I lost because I didn’t know it was a battle, or rather, I didn’t want to believe it was a battle. I could not really believe what was happening to me, even while it was happening. I wanted to believe my practitioners, my heroes, were on my side, like they were supposed to be. I could not comprehend how my ostensible allies had turned on me. My naivete, my ignorance, made me vulnerable. So much so that by the time I limped home from the hospital clutching my baby and my scarred belly, I almost felt lucky to get out alive.
When medical practitioners use the term “defensive medicine” do they ever stop to consider what that implies about their relationships with those in their care? Do they ever ponder how strange it is that those with all the power, those with the knowledge and the apparatus of medicine, consider the people under their care as a threat, as an enemy?
To practice defensive medicine is to make every clinic and hospital a battleground, and every patient a potential casualty. It warps and distorts the science of medicine and poisons the doctor-patient relationship.
My doctor-patient relationships certainly suffered. It was two years from my postpartum exam before I could go to an OB-Gyn again; even then, I’ve had to use anxiety-management techniques before I can go through with them without leaping off the table. I suffered traumatizing medical complications from my c/section, with one side effect being that my milk never fully came in and I couldn’t sustain breastfeeding. I ended up going through therapy to deal with my PTSD. My marriage was placed under severe strain for several years.
Some women turn away from medicine entirely after experiences like mine, but I haven’t done so. I still believe in science, and I still think medicine saves lives. But whatever my belief in medicine, I have a much more complicated relationship with its practitioners. I have developed a wary skepticism, and always double-check what they tell me. I am not an easy patient; I have a jaded attitude towards those who talk up a great new treatment, and a quick-flaring rage towards anyone who treats patient autonomy as unimportant or inconvenient. I ask lots of questions and I don’t always accept the answers.
Here is the result of defensive medicine as practiced on this patient: treating me with hostility has made me hostile; being abused by the system has made me angry; being lied to and manipulated has turned me into an activist for women’s medical rights in labor and birth.
And though I’m sure that’s not what its proponents intended, defensive medicine has taught me this above all: there is no safety in being a noncombatant.
Emjaybee is a writer, editor, part-time birth activist, occasional graphic designer, sometime music video producer, and mom. A traumatic unnecesarean turned her into one of those tiresome types who makes sure every pregnant woman she meets knows what EMTALA is and how to use it. She lives in Texas. @emjb