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OB/GYN Editorial May 2003
The Suit and Division Chief
Emmet Hirsch, MD
The Suit and Division Chief went to a meeting In a hospital far
away Where labors were snappy and patients were happy And most
things were mostly OK.
Said the Suit to the Chief: "I maintain
the belief That it's vital (I do not exagg) To enhance our defense
by obtaining consents For each birth, whether section or vag
Or vag For each birth, whether section or vag."
Said the Chief to the Suit, "What's
the cause and the root? This is nonsense! Explain what you meant! Can a patient
decline Mother Nature's design Through
the
lack of a formal consent? 'I demur!' cries the patient, 'I've
altered my plan I withhold my consent to proceed.' She can dream and pretend,
but the head will descend And the baby will come with all speed, All speed
And the baby will come with all speed."
The Suit then retorted, "My
will won’t be thwarted Though lay you your gripes at my doorstep.
Consents you shall have for both section and vag And for breech
and epis and for forceps!" Said the Chief (with some pluck,
for a nerve had been struck): "Don't you know you are asking
a lot of me? Are you joking or clowning? Why stop while she's
crowning To sign for an episiotomy? Oh, me! To sign for an episiotomy?!"
"If consent is your beef," cried the
horrified chief, "Then you know not the minefield you sit in, For
a signature field may be no better shield Than the paper on which
it is written." The Chief raised objections, corrections, reflections,
Which the Suit, lost in thought, didn’t hear. For he suddenly
saw there was one fatal flaw That, if fixed, made the risk disappear.
Disappear That, if fixed, made the risk disappear.
"We can beat
this whole rap," he deduced in a snap, "Just by shifting these
burdens that peeve. For the moments that start 'em are not
intrapartum But rather when couples conceive! "Consensual' sex
is the reason this vexes, So now all must prove (and be brisk!)
That discussion was had 'tween the Mom and the Dad Of alternative,
ben'fit and risk! And risk Of alternative, ben’fit
and risk!"
Those who experience a vague shudder of recognition
while reading The Suit and Division Chief should know that it is
loosely modeled after the classic Victorian nursery rhyme, The
Owl and the Pussycat. I encourage all readers who don't have
a child handy to find one so that they can engage in the delightful
experience of reading aloud Edward Lear’s far superior original.
Those
of us who practice medicine for all the right reasons (that is
to say, nearly all of us who practice medicine) may be forgiven
a small measure of resentment over recent developments. The medical
malpractice crisis and HIPAA are only the most recent additions
to a growing list of constraints to the practice of medicine. There
is more to come. Consent forms for vaginal delivery, forceps and
episiotomy may be closer than you think. Some of you already have
them.
Do not misinterpret this poem as an attempt to
belittle the important issue of informed consent. Gone are the
days of paternalistic
medicine,
and good riddance, I say. Who among us would submit to tests, treatments,
and procedures without understanding their alternatives, benefits,
and risks? Patients have benefited greatly from the value placed
on autonomy, much as they and society in general have benefited
from increased accountability, protection of privacy, regulatory
scrutiny, consideration of cost-effectiveness, and a host of other
changes. A formal and complete consent process is necessary for
ethical, compassionate, patient-centered medical practice. Certainly,
there are circumstances where even autonomy must yield to exigency,
but those are relatively uncommon even in a specialty such as obstetrics,
where on-the-spot decision-making occurs frequently. I am certain
that most of us cover all the components of properly obtained consent
in our dealings with patients. It is not the consent process that
turns us off. Rather, it is the consent form that makes many of
us physicians squirm, for the same reason that it allows our administrative
colleagues to sleep peacefully at night. Physicians, administrators,
and patients alike recognize the association between "informed
consent" and "protection from liability." This
association, along with the occasional burdening of patients with
information they neither need nor wish to know, makes many yearn
for the days when "trust" just about covered it.
Administrators
should not be criticized for cherishing the signature on a consent
form; it may indeed protect us from legal claims or
harsh awards and settlements. There may be "Suits," like
the fictitious one in the poem, who dreams of shifting the burden
of responsibility completely toward the patient by having them
sign a "conceptual consent form" detailing all the
risks and benefits of parenthood (I almost wish I had had one!).
But let us not confuse satire with reality. These considerations
are part of their job.
Our duty as physicians is clear: we must
advocate for our patients. How did the OB Practice Committee
of my division meet the challenge
of instituting informed consents in obstetrics? We chose to view
our participation not as a capitulation to protect the hospital's
financial reserves at the expense of our patients' peace
of mind, but rather as an opportunity to engage our patients
in a truly educational experience. The documents we produced were
written in that spirit. Emmet Hirsch, MD
Advisory Board Member
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