The New Yorker: 2006-10-09


I would disagree with a few things that doctor Atul Gawande has to say here - but on the whole he has some interesting opinions.

There’s a paradox here. Ask most research physicians how a profession can advance, and they will talk about the model of “evidence-based medicine”—the idea that nothing ought to be introduced into practice unless it has been properly tested and proved effective by research centers, preferably through a double-blind, randomized controlled trial. But, in a 1978 ranking of medical specialties according to their use of hard evidence from randomized clinical trials, obstetrics came in last. Obstetricians did few randomized trials, and when they did they ignored the results. Careful studies have found that fetal heart monitors provide no added benefit over having nurses simply listen to the baby’s heart rate hourly. In fact, their use seems to increase unnecessary Cesarean sections, because slight abnormalities in the tracings make everyone nervous about waiting for vaginal delivery. Nonetheless, they are used in nearly all hospital deliveries. Forceps have virtually disappeared from the delivery wards, even though several studies have compared forceps delivery to Cesarean section and found no advantage for Cesarean section. (A few found that mothers actually did better with forceps.)

Doctors in other fields have always looked down their masked noses on their obstetrical colleagues. Obstetricians used to have trouble attracting the top medical students to their specialty, and there seemed little science or sophistication to what they did. Yet almost nothing else in medicine has saved lives on the scale that obstetrics has. Yes, there have been dazzling changes in what we can do to treat disease and improve people’s lives. We now have drugs to stop strokes and to treat cancers; we have coronary-artery stents, artificial joints, and mechanical respirators. But those of us in other fields of medicine don’t use these measures anywhere near as reliably and as safely as obstetricians use theirs.

Ordinary pneumonia, for instance, remains the fourth most common cause of death in affluent countries, and the death rate has actually worsened in the past quarter century. That’s in part because pneumonias have become more severe, but it’s also because we doctors haven’t performed all that well. Research trials have shown that patients who are hospitalized with pneumonia are less likely to die if the right antibiotics are started within four hours of their arrival. But we pay little attention to what happens in practice. A recent study has shown that forty per cent of pneumonia patients do not get the antibiotics on time. When we do give the antibiotics, twenty per cent of patients get the wrong kind.

In obstetrics, meanwhile, if a strategy seemed worth trying doctors did not wait for research trials to tell them if it was all right. They just went ahead and tried it, then looked to see if results improved. Obstetrics went about improving the same way Toyota and General Electric did: on the fly, but always paying attention to the results and trying to better them. And it worked. Whether all the adjustments and innovations of the obstetrics package are necessary and beneficial may remain unclear—routine fetal heart monitoring is still controversial, for example. But the package as a whole has made child delivery demonstrably safer and safer, and it has done so despite the increasing age, obesity, and consequent health problems of pregnant mothers.

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This page contains a single entry by alicia published on January 3, 2007 7:34 PM.

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