Tuesday, August 14, 2007

The fantasy of "ideal childbirth": The Birth Plan

Creating a birth plan can be an empowering and clarifying process. Knowing your wants and expectations can help demystify the childbirth experience, and sharing your birth plan with your obstetrician is a great way to facilitate discussion and direct communication.

The reasons for having a birth plan run the gamut. Some women have the perception that a hospital birth is "over-medicalized," and a birth plan is often seen as a way to ensure a "natural" experience during labor. This may mean saying "no" to medication, an epidural or even a possible cesarean section. The other extreme may be a woman who wants an early epidural or a c-section on demand.

Every obstetrician wants one thing--flexibility on the part of the patient. While making out a birth plan can help alleviate anxiety and clarify expectations, an overly rigid birth plan can cause a great deal of misery for all involved--the patient, the patient's family and the obstetrician.

One of the most common birth plan requests that my husband receives is that no epidural be administered during labor. While some patients are able to tough out the pain, it's not uncommon for a laboring patient to request the epidural when it's too late to administer it. In one case, the laboring patient devolved into the Godzilla of patients--cursing medical staff and family, kicking wildly, and even biting her beleaguered husband, who had been trying to coach her through the pain.

Often, patients become all-consumed by the idea of the "perfect" childbirth, and to deviate from a birth plan can be perceived as a failure. However, it may be good to know that your obstetrician is also obsessed with the "perfect" childbirth though her definition may differ from yours.

The overriding goal for a physician is always the well-being of the patient and baby. While a physician will try hard to adhere to a patient's expectations, sometimes the unexpected occurs. For instance, a baby's heartbeat may dip repeatedly to the point that a physician decides a c-section is necessary.

The perfect birth plan is having both mom and baby healthy and safe, and that is one plan that both patient and doctor can agree upon.

Why we wait so long in the waiting room...

The biggest complaint that most people have is the never-ending wait in the waiting room. What exactly is going on behind those closed doors? It's an aggravating situation that is exacerbated by the demands of a bottom-line (many practices run on productivity and have to double-book to account for no-shows) and also the (sometimes unrealistic) expectations of patients themselves. It's not uncommon for a patient to want a full hour of attention when only fifteen minutes is scheduled for an appointment. Do the math, and you'll see why doctors run so far behind. Good doctors will always try to address all your issues, but sometimes it's to the detriment of a short wait.

The biggest complaint of doctors is what I describe as the "kitchen sink phenomenon." This is when patients bring EVERY complaint to a visit, usually the annual exam. Many patients "save up" their health concerns for a once-a-year visit. One of my best friends, who is an internist, regularly has patients who "kitchen sink" her. An example would be when a patient arrives for a half-hour annual exam appointment, and then comes in with a list of complaints that include high blood pressure, high cholesterol, chronic headaches, diabetes, sciatica, fibromyalgia, psoriasis, allergies, bacterial vaginosis, chest pain, depression and edema. Then there are the social issues that may be added in like domestic violence or lack of money for medications. This visit then becomes a two-hour visit because of the number of issues that need to be addressed. The kicker for my friend is when the patient will complain that not enough time was spent on her problems. And then there's the waiting room full of patients, who are angry that their appointment doesn't start on time. You can imagine it becomes a very bad day for both doctor and patient.

But there are ways to reduce the frustration. Here's how:

-If you absolutely can, ALWAYS try to schedule the first appointment in the morning. The later you schedule in the day, the more likely you will have to wait for an extended period of time.
-The average time scheduled for an appointment is fifteen minutes. Come in with a concise description of your issue. If you have a large number of health issues, the maximum number that you can probably talk about is TWO in that time slot. Again, a good doctor will never rush you out, but you may be happier about the attention to your problems if you actually devote dedicated time for each issue, especially if your health issues are chronic ones like high blood pressure or diabetes.
-If your medical practice has a website, check to see if you can download forms online. Filling out those forms ahead of time speeds up your check-in process. After all, the front desk won't kick your file back to the nurse until the paperwork is done.
-Many practices double-book appointments because of chronic no-shows as well as because of acute same-day emergencies. Double-booked appointments tend to be more egregious in the afternoon, so again, try to have a morning appointment or barring the morning, try to book the FIRST appointment for the afternoon.
-If you only have time for one appointment (or have money issues--it's true that you have to do a co-pay with each visit) but have a number of health issues, ask to speak to the doctor's nurse/medical assistant to explain the situation. The assistant may be able to talk the doctor about extending your appointment time in her books, and you may also be able to receive some feedback for less serious problems. I have yet to meet a doctor who refuses a conscientious patient's request for extra time if it's merited.

It may be that despite your best effort, you'll still have to wait. Just keep in mind that a number of things could be happening that are true emergencies. My husband had one patient whose husband was threatening to kill her because she was pregnant. She was the first patient of the day, and it basically eliminated the rest of his morning appointments. Sometimes the issues that your doctor is dealing with may be truly life or death.

The other side...

Greetings! I'm a 33 year old woman married to an ob/gyn physician somewhere in the Southeastern U.S. I've decided to create this blog to give some tips and insight from the other side of the medical visit. Most of us know what it's like to be the patient, and maybe you've wondered what goes through a doctor's mind. I'm hoping that people have BETTER visits with their physicians with some of the insights provided. I used to help run my husband's previous medical practice and so I also have experience with the business side of medicine (yes, unfortunately a medical practice has to adhere to business practices, which is a side effect of our current health care crisis--more on this later). In addition, my closest friends are physicians and their specialties run the gamut from internal medicine to psychiatry to surgery. I get to hear the war stories behind the scenes. I hope that by sharing these stories that patients will have a better understanding on what goes on in a doctor's office.