Sunday, September 30, 2007

Hat Trouble

Years ago, I was invited to observe a craniotomy. I was writing a patient education booklet about brain aneurysms at the time, and one of the doctors I had worked with extended the invitation to the medical illustrator, who was busy and passed it on to me. I was curious to see it, but I had never observed any surgeries before, and thought a craniotomy would not be a good place for a former English major to start. I had visions of fainting as the surgeon cut and peeled the skin back to reach the patient’s skull, knocking over trays of instruments with such a clatter that the surgeon’s hand would slip, with gruesome consequences.

Although I find medicine fascinating, and I’ve been known to page through pictures of diabetic foot ulcers over lunch, I am not now nor will probably ever be a clinician. I know that hands-on experience is completely different from book knowledge and PubMed articles. Since I write about medicine, though, when my husband took a business trip to Boston he brought back a Harvard Medical School baseball cap from the Coop in Harvard Square.

I’m a hat person who constantly loses hats, and I wear that hat because often I can’t find any other hats to wear as I rush out the door. Besides, the quality is quite good: cloth with a metal buckle to adjust it, rather than a cheap plastic fastener. But I knew the hat might have some unwanted consequences. I have been asked by other Moms at various playgrounds whether I went to “HMS” (to which I replied “what?” the first time someone asked). One Mom turned away in a huff when I said no.

My greatest concern about the hat is that some day I might be wearing it at a playground when a child falls and is critically injured. As the parents swarmed around to help, a Mom or Dad might turn to me and say, “You! Harvard doctor! Save this child!” I know first aid and CPR, but beyond that (ideally before I needed these skills) I would call in the professionals. Perhaps if a child is injured and a parent calls out for help, the first thing I should do is staunch the wound with my hat as I elevate it above heart level, so no one can see what it says and expect miracles.

Thursday, September 13, 2007

Lessons from Cesarean Section Rates

Evidence-based (data-driven) medicine, or EBM, is gaining momentum as an antidote to the perils of of groupthink in medicine. Just because something has "always been done this way" doesn't mean it is right; EBM argues that research data should better inform how medicine is practiced day-to-day.

It's interesting to apply EBM principles to cesarean surgery rates in this country. Far more women deliver by cesarean section now than in the past. Why? Some researchers, such as Dr. Frederic Frigoletto, Jr. at Harvard Medical School, argue that the increased rate is primarily due to complications caused by increased obesity rates and advanced maternal age. Some women also choose elective cesareans in order to control the timing and nature of the birth, he explained in a 2006 WebMD article.

Although cesarean rates have increased across the country, not every area has the same rate. Rates are generally higher in more conservative areas of the country and lower in more liberal areas. A study of California cesarean rates presented at a health policy meeting in 2000 found that the cesarean rate was up to 2.5 times higher in some regions of the state than in others. These facts have made cesarean rates a political and feminist issue as well as a medical one.

Cesarean sections are also extremely profitable for hospitals. The California study noted that cesareans are more common among for-profit hospitals than not-for-profit and teaching hospitals, which suggests a profit motive behind the surgeries as well.

On the other hand, are obesity rates (and/or maternal age) simply higher than average in some areas, potentially leading to a local increase in medically-necessary cesarean sections? If this is true, does a hospital with high cesarean rates have an ethical obligation to put some of these surgical revenues toward programs to decrease the obesity rates in its community? (Trying to decrease maternal age in a community is a thornier issue, I think). And how would this ethical obligation undermine a hospital's bottom line? A decrease in cesareans, after all, means a decrease in revenue.

Medical data is a starting point for these discussions, not an end point. All data needs some context. It's good to remember this as the presidential elections approach and the candidates try to summarize their views on the health care system into marketable sound bites. A few sentences, or a single anecdote, rarely tell the whole story.