A perspective of a retired ob-gyn on today’s situation

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A perspective of a retired ob-gyn on today’s situation

By Gwang S. Han • Guest Columnist

Obstetrics is the branch of medicine dealing with parturition, including care before and after delivery but also concerned with reproduction of society in a broader sense. The word of “obstetrics,” derived from Latin, means midwife, woman assisting the parturient, or the woman who stood by the parturient. Midwifery is a much older term than obstetrics and originated in England, being used since 1483. The British health care system has a long tradition with midwifery even during the Elizabethan era and allows more power and wider territory for midwives to maneuver and provide their own style of care.

Obstetrical services were traditionally provided by midwives in the USA, and until well into the twentieth century up to 85 percent of births were by midwives. In 1968 the American College of Nurse-Midwives was absorbed as a part of American College of Obstetricians and Gynecologists, who assumed the responsibility of educational qualifications and national certification of diplomats for title of CNM, assuring a quality standard of care nationwide. Obstetrics and gynecology had been separate and independent fields until 1931 when they were united and first board certification examination was held. In 1974, there were a little more than 10,000 board certified specialist nationwide; currently there are around 55,000, and ob-gyn’s rapidly achieving recognition as women’s primary physician.

The specialty of obstetrics and gynecology was very lately introduced west of Asheville, and in fact there had never been a specialist until I opened my solo practice in Sylva in 1974.

Sylva Hospital has long been the “go to hospital for the region,” a popular place to come seeking obstetrical care from doctors in Sylva and to deliver their babies. This trend has nothing to do with current providers in Sylva. This tradition has been established even before my arrival and in fact I was a beneficiary of that tradition.

When I arrived in Sylva in 1974, the level of obstetrical care was at a 1960 level, in my assessment. There were no dedicated nurses assigned to labor and delivery, no obstetrical anesthesia available, instruments were rudimentary, the concept of how to provide obstetrical care primitive, and there was no concept of how to manage “high-risk” obstetrical patients. My job has been two parts: first, be available for my own practice; second, I had to be readily available to any general practitioner not only in Sylva but in surrounding communities.

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It was rather precarious and potentially dangerous because of the ever-increasing threat of malpractice, but I didn’t have any option but to extend my helping hand. The number of deliveries has increased from around 300 to at its peak up to 900 per year for various reasons, but mostly due to the two steady and fairly reputable independent practitioners providing service in Sylva, in my case for 33 years. However, there has been a varied number of obstetricians practicing in Sylva — from two to six — competing in a business sense during my practice time.

Hospitals can’t stay in business unless they generate enough revenue to meet payroll, to upgrade and improve the hospital and recruit new physicians. The hospital and physicians in the community have to provide better care in unison than surrounding community hospitals to attract clients (patients). The U.S. birth rate 2013 was 63 per 1,000 women of childbearing age (age 15-45). My rough estimate is that this would be about 350 births per year in Jackson and Macon counties if the residents of each county decided to stay within their borders. So obviously Sylva hospital attracts more clients from surrounding communities.

The main story in the newspaper involves the one particular individual in the practice in Sylva, monopolized and “megalithic,” the only rolling musical chair that lost all her employees including two physicians and three midwives. The reason why and how was not elaborated in the newspaper. I suppose she had that many employees by recruitment, consolidation and possibly with a strong support and financial assistance from the hospital. There are two newly opened group practices, one by the Sylva hospital group and the other by Memorial Mission Hospital (MMH); a new kid in the block hiring three midwives who vaulted out from the “megalithic” practice. It appears to be none other than her own making although she seems to be trying to portray herself as a victim. I have to respect those professionals and their own decision.

However there are two stories, disturbing and intriguing, in the newspaper article. A young physician made a statement saying doctors practicing in Sylva don’t push for unnecessary interventions, claiming low cesarean section rate of 17 percent (nationwide it is 22 to 23 percent). She insinuates that the obstetricians are as qualified as she or perhaps better, but in other towns have been doing inappropriate cesarean sections.

Statistics would be meaningless unless there is a critical mass to analyze from. However, I am very concerned with such a low number and would rather look into peri-natal mortality and morbidity of this hospital to see whether the quality of care has been compromised. Complications in maternity care happen very randomly and are unpredictable in occurrence. Furthermore, it is almost impossible to have thorough peer reviewing in such a small hospital like the one in Sylva.

The intriguing story is the announcement by Harris administrator “promoting the fact the four providers who deliver there are all physicians.” He knows that the major workforce in his hospital has been midwives delivering mostly vaginal births during last seven years and generating quite a substantial revenue not only for their employer but for the hospital as well. Had he believed in inferiority of quality of care by midwives, it would be indeed derelict of his duty to let them keep practicing the way it has been. The role of midwife in the maternity care has been well established in this community because of their superb performance and conduct of ethical practice even before his arrival.

Why now try to make a distinction? If his intention is trying to send a message as if something may not be right in midwives’ practice, he should feel ashamed. By nature of training of midwives and in the goal clearly defined in their association, they job is confined in care of normal uncomplicated pregnant women helping vaginal birth. Their performance must have been good enough to be hired by MMH group, possibly the major threat to his hospital.

Competition is the core of capitalism that brings the quality of service and lowers the cost. Medical business should not be different from any others. I would encourage fair competition as well as collaborative work ethics in the three groups of practice instead of any dirty game plan that would stir mud and induce nefarious odor. In fact I am very happy for the consumers (patients) in this region having another choice with newly opened MMH group. Welcome aboard.

(Gwang S. Han, MD, was the first board certified specialist in ob-gyn west of Asheville. He practiced for 33 years in Sylva, retiring in 2007, originally coming from Korea in 1967.)

Editor’s Note: This column was submitted after an article on ob-gyn practices ran in late November in The Smoky Mountain News. That article can be read at http://www.smokymountainnews-.com/news/item/14658

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