The great debate: Cameras in the delivery room

For most parents, few things can match the wonder of photos and video capturing the arrival of a new child into the world.

But at some hospitals, families who bring a camera into the delivery room will be informed that picture-taking is off limits. This is the policy at several hospitals in Maryland and at least one in Massachusetts, where neither photos nor video are allowed until after the baby is safely delivered and the medical team has given permission for pictures.

It’s a substantial reversal to the long-standing practice of encouraging families to be involved and engaged in the birth of their child, and it has sparked some passionate debate about the pros and cons of allowing cameras in the delivery room. The New York Times led the pack with a recent story and online discussion about the issue.

Here’s some background from the Times article, which includes the story of a Maryland mom who was so upset about the camera restrictions that she started an online petition:

For the hospital, the issue is not about rights but about the health and safety of the baby and mother and about protecting the privacy of the medical staff, many of whom have no desire to become instant celebrities on Facebook or YouTube.

Their concerns come against a backdrop of medical malpractice suits in which video is playing a role. A typical case is one settled in 2007 that involved a baby born at the University of Illinois Hospital with shoulder complications and permanent injury; video taken by the father in the delivery room showed the nurse-midwife using excessive force and led to a payment to the family of $2.3 million.

Nationwide, photography and videography have been allowed in many delivery rooms for decades. But in recent years, technology creep has forced some hospitals to rethink their policies as they seek to balance safety and legal protection against the desire by some new mothers to document all aspects of their lives, including the entire birth process.

It’s seems there’s plenty to argue about. At the Times’ “Room for Debate” opinion section, an obstetrician-gynecologist questions how far parents should go in capturing and sharing the birth experience. “The first time I saw a camera lens creeping into my field of view while delivering a baby, I thought the biggest issue was the appropriateness of exposing others to really intimate videos,” wrote Dr. Amy Tuteur. “Our vacation videos are bad enough. Are we really going to force friends and relatives to watch such a personal event?”

Photographing or videotaping a live birth is a decision that ought to be negotiated between the parents and the OB team, she concluded.

Jennifer Margulis, a contributing editor with Mothering magazine had a completely different take: “Anytime you’re told you may not record what happens to you, be very wary of the people you are dealing with… Hospitals don’t want you taking pictures because they fear you might record their mistakes.”

At a deeper level, the whole debate raises issues about how we experience major life events when there’s a camera involved, says Raymond DeVries, a professor with the Center for Bioethics and Social Sciences in Medicine at the University of Michigan Medical School. If you’re going to bring a camera into the delivery room, think twice, he wrote. “Birth is an intimate moment to be experienced and cherished. Women in labor should not be thinking ‘I’m not decent for Facebook.’ When the camera is calling the shots we have lost something precious about human experience.”

The delivery room seems to be the flashpoint for a larger shift in how we view privacy and patients’ expectations of participating in their health care. Several months ago I blogged about allowing family members in the room when someone is being resuscitated. Do families have the right to be present, even when what they’re witnessing is bound to be disturbing and might invade the patient’s privacy? Many would argue that they do, but it has made for considerable tension between patients and health care professionals.

Health care workers often are ambivalent about the lengths to which they can accommodate the wishes of patients and families. What if a family member wielding a video camera gets in the way at a crucial moment? What if the family’s presence becomes disruptive?

The privacy boundaries can sometimes be exceeded for health care workers as well as for patients. Consider a 2007 incident at Children’s Hospital in Boston, where the family of a young cancer patient installed a webcam in the child’s hospital room so a favorite relative could see what was happening – but staff didn’t know the webcam was there until it was accidentally discovered by a nurse.

Judging from the online discussion at the New York Times, it’s a volatile topic. An anesthesiologist who attends C-sections wrote that “the focus needs to be on the patient and not rescuing a visitor from the floor after they have fainted (yes, it happens a lot).” From someone else: “It’s a medical procedure, not a fraternity kegger, for Pete’s sake. Why do people treat everything like it’s primarily some sort of photo op?”

A mother wrote:

I expressly forbade family members from videotaping me during labor and delivery. It’s not a pretty process in the best of circumstances, and still snapshots of me holding the baby after arrival suffice for commemorating the occasion. I don’t comprehend the sort of exhibitionism that would drive someone to want their delivery posted on Facebook.

Someone else argued that cameras are everywhere and we need to get used to it. “Cameras are documenting many facets of our lives and medical people should not be treated any different than other people,” he wrote.

Another commenter wondered whatever happened to pleasing the customer: “I’m not spending $10,000 a year on insurance to have my service providers dictate chapter and verse of how I experience the care I pay them to provide.”

It seems reasonable for hospitals to have some basic rules about the presence of cameras in the delivery room, if for no other reason than to make it clear what’s expected of families and to prevent the picture-taking from becoming disruptive. How far a hospital’s policy should go is less clear. Should there be an outright ban on photos and videos during the actual delivery? Should this be negotiated on a case-by-case basis between families and the OB team? What do readers think?

Photo courtesy of Brent and Gretchen Schlosser

Busting the malpractice myths

It’s a common view that malpractice lawsuits are clogging up the American legal system and that many, if not most, patients who sue wind up with multimillion-dollar settlements.

But is this belief supported by the evidence? Apparently not, according to a recently released benchmarking report by Zurich, one of the top insurers of hospitals and health care organizations in North America.

Zurich collected data from 1,600 hospitals for 1997 through 2007. The main findings: There was a slight decline in the frequency of malpractice claims over the decade, and the average amount per claim has leveled off.

Teaching hospitals and children’s hospitals were the most likely to be sued for a large amount; nonprofit hospitals were the least likely. Community hospitals and outpatient facilities were somewhere in the middle. The reason for these differences isn’t entirely clear, although it might be at least partially explained by the fact that teaching hospitals often see patients who are sicker or have more complex or unusual illnesses.

The states with the highest claim severity were New York, Illinois and Pennsylvania.

The report more or less confirms what other studies have found: People do not necessarily go rushing to a lawyer after a bad outcome, and they don’t generally prevail when their grounds for a lawsuit are flimsy.

Pennsylvania, for instance, is considered one of the riskier states when it comes to malpractice litigation. Yet data for 2008 showed the number of lawsuits had decreased substantially, from 2,632 in 2000 to 1,602 eight years later. Only about 10 percent of the cases in 2008 actually went to trial, and the health care provider(s) prevailed 80 percent of the time.

And this study, which appeared in the New England Journal of Medicine in 2006, reached similar conclusions. The researchers collected random closed-claim samples and reviewed them, assigning a six-point scale according to the likelihood that medical error resulted in a bad outcome for the patient. They found that 80 percent of the claims involved significant injury resulting in disability or death. Slightly more than half of the plaintiffs were awarded damages, the average being $485,348. On the other hand, cases that went to trial were more likely to be those of questionable merit.

Although this study has been interpreted by more than a few observers as evidence that it’s mostly frivolous claims that end up in court, the researchers didn’t see it this way. Their take: It sometimes can require going to court for patients, families and their attorney to discover what actually happened that led to a bad outcome.

Of particular note, one in six of the claims the researchers examined involved an error by a clinician, yet the patient and/or family received no compensation. Most national estimates suggest that only about 10 percent of patients who are injured ever seek compensation. Maybe it’s because Americans aren’t as litigious as everyone thinks, or maybe it’s because injured patients aren’t being told the full truth.

Here’s the real clincher from the NEJM study’s authors:

Our findings suggest that moves to curb frivolous litigation, if successful, will have a relatively limited effect on the caseload and costs of litigation. The vast majority of resources go toward resolving and paying claims that involve errors. A higher-value target for reform than discouraging claims that do not belong in the system would be streamlining the processing of claims that do belong.

High-profile, multimillion-dollar cases tend to grab the public’s attention. From there, it’s a short leap to assuming these types of cases are common. But this is anecdotal at best, and the statistics don’t back this up. Maybe the discussion about tort reform would be less volatile if the emphasis was on fact rather than emotion.

Photo: Wikimedia Commons

Fear of litigation

It has long been known that hospital emergency rooms are one of the most expensive places to receive care. There are many reasons why this is so, but the main factor is the inherent nature of emergency care: fast-paced and resource-intensive, with everything to lose if a potentially lethal illness or injury is somehow overlooked or misdiagnosed.

The pressure to overtest and overtreat is enormous, as an Associated Press story recently explained:

The fear of missing something weighs heavily on every doctor’s mind. But the stakes are highest in the ER, and that fear often leads to extra blood tests and imaging scans for what may be harmless chest pains, run-of-the-mill head bumps, and non-threatening stomachaches.

Many ER doctors say the No. 1 reason is fear of malpractice lawsuits. "It has everything to do with it," said Dr. Angela Gardner, president of the American College of Emergency Physicians.

The fast ER pace plays a role, too: It’s much quicker to order a test than to ask a patient lots of questions to make sure that test is really needed.

If you haven’t been following the Associated Press’s "Overtreated" series, I’d urge you to do so. Besides tackling the overall mindset that "more is better," the various installments in the series have addressed back pain, cancer screening, medical imaging and end-of-life care. You also can find a great multimedia interactive tool here.

The concept of overtreatment isn’t something many Americans are accustomed to talking about. Although it’s easy to blame physicians for ordering too many expensive tests or prescribing too many expensive drugs, the fact is that consumers share some of the responsibility. As the AP story points out, patients’ expectations are often high:

Many think every ache and pain deserves a high-tech test.

"Our society puts more weight on technology than on physical exams," Gardner said. "In other words, why would you believe a doctor who only examines you when you can get an X-ray that can tell something for sure?"

Refusing those demands creates unhappy patients. And concern that unhappy patients will sue remains the elephant in the emergency room.

In light of this, it was interesting to come across a newly released study in the Archives of Internal Medicine that found nine in 10 physicians who responded to a survey believed doctors overtest and overtreat to protect themselves from being sued. The survey involved more than 1,200 physicians nationwide and included emergency-room doctors, primary care doctors and surgeons. The vast majority of the physicians who were surveyed said they believed it would help decrease unnecessary testing if physicians didn’t have to fear unwarranted accusations of malpractice.

What we have here is a standoff: fear of litigation and a long-standing philosophy that more medicine is better medicine vs. valid concerns about the cost and potential harms of overtreatment. Until we figure out how to reconcile these opposing beliefs, bringing down the cost of health care in the U.S. will likely continue to be an uphill battle.

A failure of transparency

The patient was planning to have her gall bladder removed. Before the procedure, she met with the surgeon to talk about the risks and the surgeon’s skill and experience with laparoscopic surgery. Among the questions the patient asked: Had the doctor ever been sued for malpractice or had sanctions against his medical license? He said no.

You’ve probably guessed where this is heading. During the surgery the patient’s intestine was perforated and she developed an infection. She later found out the surgeon was disciplined subsequent to having a patient die after undergoing the same procedure.

The woman sued, alleging malpractice and lack of informed consent. She lost. Now the case is headed for a retrial after the U.S. appellate court sided with the plaintiff’s appeal of the verdict. At the heart of the issue is whether the trial court erred in tossing out the argument that the physician’s deceit constituted a breach of the patient’s right to informed consent.

I stumbled across this fascinating legal case this week at the Shrink Rap blog, where it has generated considerable discussion. It raises some compelling questions about patients’ rights to informed consent and the extent of the information physicians should be expected to disclose. Shrink Rap wonders how far it should go:

What if the issue wasn’t technical competence? How much “personal background” should a doctor have to tell a patient before treatment can begin? Medical school grades? Failure to pay income tax? Should doctors be required to disclose to patients the fact that they’ve been treated for mental illness themselves?

Grade point average? Income taxes? I have a hard time picturing any kind of case law that would justify this level of prying. That doesn’t appear to be what this case is about, though. It seems to me that the physician’s competence and experience is highly relevant to informed consent. If this patient had known ahead of time that the surgeon was disciplined following the death of a patient – a death involving the same procedure the patient was about to undergo – it’s possible she would have chosen a different surgeon.

And outright dishonesty adds a whole new wrinkle to the case. Is it ever OK for a physician to dissemble in response to a patient’s question? One of the commenters at Shrink Rap concludes it was “moral turpitude, maybe, but not malpractice… Patients have a right to ask any question they want to ask. Doctors have a right to decline to answer, then the patient can decide how to proceed.”

Others disagreed. From one commenter: “It’s not his right to lie to the patient so they’ll sign the consent form so he can make money.” From someone else:

I disagree about it being an issue of “personal background.” Whether or not the doctor had previously lost patients from that procedure, and whether or not he had had action taken against him is professional background, not personal. “Personal” that it affects only the private life of the individual in question. Just because something could go wrong no matter how skilled the surgeon doesn’t justify lying about the outcome of prior surgeries, especially given that the patient directly asked. It wasn’t a lie of omission, it was a flat-out lie about something that the patient clearly considered important information to their decision about the surgery.

I personally think it was a smart question to ask, and one that most medical professionals shouldn’t hesitate to answer honestly.

It’s actually not that hard to find out whether a physician has a valid license or has ever had sanctions against his or her medical license. In Minnesota, the database is maintained by the Board of Medical Practice and it’s easily searchable online. I’m not sure, however, that we can assume most patients know this. The burden tends to be on consumers to either do their own homework, or to be savvy enough to ask the physician (and hope they get an honest answer).

By sheer coincidence, the Center for Public Integrity issued a report this week that takes policymakers to task for failing to make the National Practitioner Data Bank more accessible to the public. The report notes that while the public can view statistical portions of the NPDB, “the law blocks public users from pulling up histories of individual doctors or other health care professionals. Only authorized users such as hospital administrators can do that. A physician can see only his or her own record.”

Theres a complicated push-and-pull over how much information consumers/patients should have. Where should the boundaries be drawn? How much decision-making power should consumers be given? How much of this power are they capable of handling? We haven’t figured it out yet, and I think we’re going to be debating this for a long time to come. While I don’t expect the retrial of the case involving the dishonest surgeon to completely rewrite case law, perhaps it’ll add another layer of insight into how we define informed consent and what level of disclosure is due between physician and patient.