EDITORIAL
Getting Along Timothy Rowe, MB BS, FRCSC Editor-in-Chief
J
ust about every area of human endeavour has its professionals, and we rely on the advice (and honour able intentions) of our professional advisors. With medical issues, ostensibly this still applies, but exactly who is a medical professional and who isn’t has become a little murky. Ready Internet access to medical information has made diagnosticians of all of us, because, hey, making a diagnosis is just using an algorithm, right? And the paradigm of orthodox (science-based) medicine has been challenged by “healing” practices based on alternative ideas about how health is maintained. Nevertheless, for most people (and most governments) the medical profession has remained the arbiter of what constitutes medical practice and what does not. The buck stops here. And yet there are areas of medicine where the primacy of the medical profession is not unequivocally accepted. Musculo-skeletal pain is one of these. Having vague physical symptoms, headed by lethargy, is another. In any area where there is limited objective scientific evidence, alternative medicine practitioners thrive, their focus on individualized treatment trumping orthodox medicine’s approach of ruling out serious conditions and then providing mostly reassurance. When treatment is actually indicated, the fact that the treatments suggested by alternative care providers involve changes in diet, dietary supplements, or manipulations rather than use of medication or surgery make them inherently more acceptable to patients— regardless of whether they are actually going to help. What patients want, and are most comfortable with, tends to guide what management they will accept. For most people, simpler and less technological approaches seem to be more generally acceptable than complicated or aggressive ones. In dealing with a medical issue, the medical profession is concerned primarily with outcomes, but the patient and other care providers are equally concerned with the process; that is, what form their management takes. This also applies to pregnancy; although I’m generalizing here, most pregnant women are concerned with having a healthy
baby (which is also what concerns their physicians), but they are also concerned with how they will get that healthy baby. In the report from the SOGC’s Health Human Resources Project on Intrapartum Emergency Obstetrical Care, women who were planning pregnancy said that they expected to have a choice of caregiver, to be attended at delivery by the person who provided their prenatal care, and to have timely and attentive care provided during labour and delivery, with due respect for their birth plan and expectations.1 In other words, the idea that pregnant women will passively accept interventions is mostly not true. They will want to know why something is being done, and to have the right to refuse. Michael Klein and colleagues reported that Canadian obstetricians tend to favour a technological approach to labour and delivery, while Canadian midwives and doulas favour approaches that do not include technology; nurses and family physicians providing intrapartum care had views falling between those of obstetricians and midwives.2 Favouring a technological approach to labour and delivery is not, by itself, a bad thing; but in the Canadian Maternity Experiences Survey, satisfaction with the experience was rated as “very high” by 71% of women attended by midwives and by 52% of women attended by obstetrician-gynaecologists.3 It seems that for obstetricians, usually the end justifies the means; midwives aren’t so sure. In this issue of the Journal, Jillian Ratti and colleagues conclude, from the results of a survey done in the Calgary area, that relationships between midwives and physicians are sometimes strained.4 The strain appears to originate in their divergent views of childbirth, with the majority of obstetricians believing that childbirth is a dangerous process while only 4% of midwives agree. Further, many more physicians than midwives believe that today’s low levels of infant mortality are due to modern obstetrical interventions. Can these divergent perspectives be reconciled? Should they be? J Obstet Gynaecol Can 2014;36(7):571–572
JULY JOGC JUILLET 2014 l 571
EDITORIAL
From 2004 to 2006, Health Canada funded the Multidisciplinary Collaborative Primary Maternity Care Project, intended to facilitate implementing collaborative strategies to meet the needs for maternity care in Canada in the face of developing shortages of physicians, midwives, and nurses.5 At least a decade ago, opinion leaders felt that Canada was facing a major shortage of human resources in maternity care, and that collaborative practices among different groups of care providers was the best means of mitigating the effects of this shortage. The principals of the national Maternity Care Project recommended the development of a pan-Canadian network to facilitate implementation of collaborative care models. 5 This network has not been established, and there is little indication that it will be; a qualitative study involving representatives of all Canadian professional associations having a stake in such a network identified significant barriers to collaboration, and concluded that strong leadership would be required to get any such initiative off the ground.6 Among the barriers identified were the varied fee structures for each group of practitioners, liability issues (a major concern for obstetricians), and interdisciplinary rivalry, including a lack of respect between disciplines and concerns about “turf protection.” Despite these barriers, there are grounds for optimism that collaboration will ultimately become the norm. Both Klein et al.2 and Ratti et al.4 identified the willingness of members of different disciplines to work towards collaboration. Increasing the exposure of trainees in each discipline to the work of colleagues in other disciplines would reduce misconceptions, increase understanding of each discipline’s perspective, and smooth the path to getting along better. It could, in fact, do more than that:
572 l JULY JOGC JUILLET 2014
in 2012, a retrospective study of women who attended a collaborative interdisciplinary maternity care program in Vancouver found that they had a lower rate of Caesarean section and shorter hospital stays than matched control subjects.7 So it seems that we can all learn from one another. I know that’s an over-simplification, but I’m biased: my initial obstetric training was provided entirely by midwives. I’ve never forgotten. REFERENCES 1. Society of Obstetricians and Gynaecologists of Canada. Health Human Resources Project on Intrapartum Emergency Obstetrical Care. Available at: http://sogc.org/wp-content/uploads/2012/09/hhr-survey-report_e.pdf. Accessed May 11, 2014. 2. Klein MC, Kaczorowski J, Hall WA, Fraser W, Liston RM, Eftekhary S, et al. The attitudes of Canadian maternity care practitioners towards labour and birth: many differences but important similarities. J Obstet Gynaecol Can 2009;31:827–40. 3. Chalmers B, Dzakpasu S, Heaman M, Kaczorowski J; for the Maternity Experiences Study Group of the Canadian Perinatal Surveillance System, Public Health Agency of Canada. The Canadian maternity experiences survey: an overview of the findings. J Obstet Gynaecol Can 2008;30:217–28. 4. Ratti J, Ross S, Stephanson K, Williamson T. Playing nice: improving the professional climate between physicians and midwives in the Calgary area. J Obstet Gynaecol Can 2014:36:590–7. 5. Multidisciplinary Collaborative Primary Maternity Care Project. Final report. Available at: http://sogc.org/wp-content/uploads/2013/09/ repFinlHlthCA0606.pdf. Accessed May 11, 2014. 6. Peterson WE, Medves JM, Davies BL, Graham ID. Multidisciplinary collaborative maternity care in Canada: easier said than done. J Obstet Gynaecol Can 2007;29:880–6. 7. Harris SJ, Janssen PA, Saxell L, Carty EA, MacRae GS, Petersen KL. Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. CMAJ 2012;184:1885–92.
Getting Along Timothy Rowe, MB BS, FRCSC Editor-in-Chief
J
ust about every area of human endeavour has its professionals, and we rely on the advice (and honour able intentions) of our professional advisors. With medical issues, ostensibly this still applies, but exactly who is a medical professional and who isn’t has become a little murky. Ready Internet access to medical information has made diagnosticians of all of us, because, hey, making a diagnosis is just using an algorithm, right? And the paradigm of orthodox (science-based) medicine has been challenged by “healing” practices based on alternative ideas about how health is maintained. Nevertheless, for most people (and most governments) the medical profession has remained the arbiter of what constitutes medical practice and what does not. The buck stops here. And yet there are areas of medicine where the primacy of the medical profession is not unequivocally accepted. Musculo-skeletal pain is one of these. Having vague physical symptoms, headed by lethargy, is another. In any area where there is limited objective scientific evidence, alternative medicine practitioners thrive, their focus on individualized treatment trumping orthodox medicine’s approach of ruling out serious conditions and then providing mostly reassurance. When treatment is actually indicated, the fact that the treatments suggested by alternative care providers involve changes in diet, dietary supplements, or manipulations rather than use of medication or surgery make them inherently more acceptable to patients— regardless of whether they are actually going to help. What patients want, and are most comfortable with, tends to guide what management they will accept. For most people, simpler and less technological approaches seem to be more generally acceptable than complicated or aggressive ones. In dealing with a medical issue, the medical profession is concerned primarily with outcomes, but the patient and other care providers are equally concerned with the process; that is, what form their management takes. This also applies to pregnancy; although I’m generalizing here, most pregnant women are concerned with having a healthy
baby (which is also what concerns their physicians), but they are also concerned with how they will get that healthy baby. In the report from the SOGC’s Health Human Resources Project on Intrapartum Emergency Obstetrical Care, women who were planning pregnancy said that they expected to have a choice of caregiver, to be attended at delivery by the person who provided their prenatal care, and to have timely and attentive care provided during labour and delivery, with due respect for their birth plan and expectations.1 In other words, the idea that pregnant women will passively accept interventions is mostly not true. They will want to know why something is being done, and to have the right to refuse. Michael Klein and colleagues reported that Canadian obstetricians tend to favour a technological approach to labour and delivery, while Canadian midwives and doulas favour approaches that do not include technology; nurses and family physicians providing intrapartum care had views falling between those of obstetricians and midwives.2 Favouring a technological approach to labour and delivery is not, by itself, a bad thing; but in the Canadian Maternity Experiences Survey, satisfaction with the experience was rated as “very high” by 71% of women attended by midwives and by 52% of women attended by obstetrician-gynaecologists.3 It seems that for obstetricians, usually the end justifies the means; midwives aren’t so sure. In this issue of the Journal, Jillian Ratti and colleagues conclude, from the results of a survey done in the Calgary area, that relationships between midwives and physicians are sometimes strained.4 The strain appears to originate in their divergent views of childbirth, with the majority of obstetricians believing that childbirth is a dangerous process while only 4% of midwives agree. Further, many more physicians than midwives believe that today’s low levels of infant mortality are due to modern obstetrical interventions. Can these divergent perspectives be reconciled? Should they be? J Obstet Gynaecol Can 2014;36(7):571–572
JULY JOGC JUILLET 2014 l 571
EDITORIAL
From 2004 to 2006, Health Canada funded the Multidisciplinary Collaborative Primary Maternity Care Project, intended to facilitate implementing collaborative strategies to meet the needs for maternity care in Canada in the face of developing shortages of physicians, midwives, and nurses.5 At least a decade ago, opinion leaders felt that Canada was facing a major shortage of human resources in maternity care, and that collaborative practices among different groups of care providers was the best means of mitigating the effects of this shortage. The principals of the national Maternity Care Project recommended the development of a pan-Canadian network to facilitate implementation of collaborative care models. 5 This network has not been established, and there is little indication that it will be; a qualitative study involving representatives of all Canadian professional associations having a stake in such a network identified significant barriers to collaboration, and concluded that strong leadership would be required to get any such initiative off the ground.6 Among the barriers identified were the varied fee structures for each group of practitioners, liability issues (a major concern for obstetricians), and interdisciplinary rivalry, including a lack of respect between disciplines and concerns about “turf protection.” Despite these barriers, there are grounds for optimism that collaboration will ultimately become the norm. Both Klein et al.2 and Ratti et al.4 identified the willingness of members of different disciplines to work towards collaboration. Increasing the exposure of trainees in each discipline to the work of colleagues in other disciplines would reduce misconceptions, increase understanding of each discipline’s perspective, and smooth the path to getting along better. It could, in fact, do more than that:
572 l JULY JOGC JUILLET 2014
in 2012, a retrospective study of women who attended a collaborative interdisciplinary maternity care program in Vancouver found that they had a lower rate of Caesarean section and shorter hospital stays than matched control subjects.7 So it seems that we can all learn from one another. I know that’s an over-simplification, but I’m biased: my initial obstetric training was provided entirely by midwives. I’ve never forgotten. REFERENCES 1. Society of Obstetricians and Gynaecologists of Canada. Health Human Resources Project on Intrapartum Emergency Obstetrical Care. Available at: http://sogc.org/wp-content/uploads/2012/09/hhr-survey-report_e.pdf. Accessed May 11, 2014. 2. Klein MC, Kaczorowski J, Hall WA, Fraser W, Liston RM, Eftekhary S, et al. The attitudes of Canadian maternity care practitioners towards labour and birth: many differences but important similarities. J Obstet Gynaecol Can 2009;31:827–40. 3. Chalmers B, Dzakpasu S, Heaman M, Kaczorowski J; for the Maternity Experiences Study Group of the Canadian Perinatal Surveillance System, Public Health Agency of Canada. The Canadian maternity experiences survey: an overview of the findings. J Obstet Gynaecol Can 2008;30:217–28. 4. Ratti J, Ross S, Stephanson K, Williamson T. Playing nice: improving the professional climate between physicians and midwives in the Calgary area. J Obstet Gynaecol Can 2014:36:590–7. 5. Multidisciplinary Collaborative Primary Maternity Care Project. Final report. Available at: http://sogc.org/wp-content/uploads/2013/09/ repFinlHlthCA0606.pdf. Accessed May 11, 2014. 6. Peterson WE, Medves JM, Davies BL, Graham ID. Multidisciplinary collaborative maternity care in Canada: easier said than done. J Obstet Gynaecol Can 2007;29:880–6. 7. Harris SJ, Janssen PA, Saxell L, Carty EA, MacRae GS, Petersen KL. Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. CMAJ 2012;184:1885–92.
