J.D. Kleinke on Defensive Medicine, Obstetrics and Women's Health

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By Jill Arnold


J.D. Kleinke, author, medical economist and health care information technology pioneer wrote an article titled, A Normal Pregnancy is a Retrospective Diagnosis, which was featured today on The Health Care Blog. At the risk of deterring readers from clicking over to read the entire piece by zealously pulling excerpts of interest, I am pasting the passages here while imploring that you read his work.

Having the honor of currently reading an advance copy of his new book, Catching Babies, makes me want to refrain from intermingling my words with his, as his apt description of the cultural norming of defensive medicine and how women’s reproductive health bears the disproportionate burden of practice variation and angst needs no prefacing or commentary from me.


In obstetrics, “defensive medicine” is not just assumed, but actively evoked as part of a normative explanation for medical decisions. I have heard the phrase “we have to do this to cover ourselves legally” uttered to patients with such frequency, it has gone from appallingly crass, to admirably candid, to nearly superfluous.



Whether or not this does explain every dysfunction in obstetrical care, as many would have us believe, medicine does not get any more defensive that this: the inexorable increase in birth interventions has driven a growing number of women away from the medical establishment, off the grid, to home births attended by “lay” or unlicensed midwives. It has spawned a cottage industry of “alternative birthing” activists. And it has inspired language no less ugly than terms like “birth rape” (seriously - Google it) to describe what many view as a mangling of womens’ bodies against their will by OB/GYNs held hostage by lawyers who do not ambulance-chase malpractice so much as hearse-chase mal-outcomes - many of which are the fault not of any doctor, but of nature, God, or bad luck, depending on your beliefs.



Our medical malpractice system, like much of the post-modern American health care system itself, is a house of broken mirrors for our own worst neuroses as a society; and a big part of these neuroses includes our pathologizing of childbirth, along with our pathologizing of shyness, baldness, the normal effects of aging, dry eyes, twitchy legs, and whatever other little misery we can figure out how to medicate next.



As Americans, we seem hellbent on controlling the uncontrollable; this is why we create so many breathtaking medical technologies and give the world almost all of its breakthroughs in the treatment of cancer, heart disease and other real diseases. 



In my earlier work about the economic and political conflicts that define the delivery of health care in the US, I kept noticing that the greatest variations in care - and deepest cultural angst and antagonisms - seemed always to be associated with women’s health: our grossly disproportionate misdiagnosis and undertreatment of heart disease in women; our obsession with breast cancer when lung cancer is far deadlier and far more preventable; the almost criminal variations in hysterectomy rates around the country; the uninformed, blanket imposition of one group’s religious values on all women’s reproductive decisions.