Non-MD Medical Providers Performing Abortions in California

We are getting there!  As you, my readers know, The Blog has been a champion of non-physician medical care, knowing full well that properly trained, skilled nurse practitioners and physician assistants are highly qualified to provide such service.

Gov. Jerry Brown of California has signed into law a bill that will permit nurse practitioners, midwives and physician assistants to perform all forms of abortion, including surgical abortions.  Those opposed to abortions are maintaining that the new law will "reduce the medical standards for abortion," thereby "reducing safety."(1)

Ridiculous.  This bill will put the procedure within reach of women who often live in settings where physician-provided abortions are difficult to access, and provide them with skilled practitioners.

You do not have to be a physician to perform an abortion.  You do not have to be a physician to perform many forms of surgery.  You do not have to be a physician to perform many emergency medical procedures. You do not have to be a physician to provided excellent general (or even specialized medical care).

An interesting article in the recent edition of The New England Journal of Medicine (2) concluded that he best surgery is carried out by the physicians with the greatest "skills," not necessarily those with the best training.  "Our study showed wide variation in technical skill among fully trained, practicing surgeons." (2)

Academic training is one thing.  Developing the necessary skills is something else.  And, you know, there are many skilled non-MD practitioners who may be far more skilled than those with MD degrees.  Trust your experienced, skilled non-MD medical provider - your physician often does, the city government does (EMTs, etc.), the armed services do (front-line medics) - and so should you.

1. New York Times, Oct. 10.
2. The New England Journal of Medicine, Oct. 10.

What a Hospital Ad Does Not Tell You

"The thousands of minimally invasive procedures performed by our cardiac surgeons have shown shorter hospital stays and reduced recovery time, among other benefits.  This proven record of strong outcomes is why we are nationally ranked in cardology and heart surgery by U.S. News and World Report."

This full page advertisement by NYC Langone Medical Center,  on the back page of the Business Section of The New York Times (Oct 1) must have cost quite a bit.

You need to notice what it does not say.  It says nothing about actual long-term outcomes.  It says nothing about the success of the procedures.  It says nothing about re-admission rates, it says nothing about infection rates.  It says nothing about morbidity and mortality rates.  It says nothing about actual diagnoses and statistics regarding each form of abnormality treated.

Please readers, pay no attention to such ads.  The only useful information contained therein is that minimally invasive heart surgery techniques are available at Langone (as they are, by the way, at most all major cardiovascular surgical centers in the United States).

Below is a summary of the state of minimally invasive surgery from a recent NIH review:


1. Minimally invasive cardiac surgery (MICS) represents a safe and effective approach for a variety of cardiac surgical diseases.
2. MICS does not appear to result in differences in short- or long-term survival compared with the sternotomy approach.
3. MICS may be associated with lower rates of perioperative complications in certain instances.
4. MICS appears to result in decreased length of hospitalization, improved pain control and faster recovery to normal activities.
5. Continued research is necessary to assess long-term outcomes of minimally invasive approaches.
6. With regard to outcome measures such as quality of life, minimally invasive approaches may be the standard on which to compare evolving percutaneous technologies.

Pay particular attention to statements No. 2 and No. 5.

When choosing your medical center and your surgeon, ask the right questions - be fully informed.  Do not pay attention to these expensive marketing techniques that many medical centers are now using to increase their market-share!

This Is a Hospital, Not a Hotel

"You have to realize that this is a hospital, not a hotel," was my standard response to the "hospitality" criticisms offered by the parents of my patients (I am a retired pediatric cardiologist).

Apparently this attitude no longer applies.  In a NY Times Sunday Review article entitled "Is This a Hospital or a Hotel?" (Sep 22)  Dr. Elisabeth Rosenthal analyzes the new approach that hospitals are taking.  The chief executive of a new hospital opening next year "exulted" in saying: "You feel like you could be at the Marriott."  The hospital "business" has become extremely competitive, for better or worse, and hospitals are improving their bottom line, not by increasing quality of medical care, but by increasing the quality of "hotel" services - such as hiring "celebrity chefs" to provide special menus, including quality wines.  Major hospital systems are averaging $4.5 million annually in advertising alone! Dr. Rosenthal points out that reducing the rate of medication error is not what "sells" beds. More and more it has become amenities, amenities, and amenities.  She goes on to point out that the Henry Ford health system in Michigan recently hired a hotel executive to run its newest hospital, located in the upscale city of Bloomfield.

Believe it or not, a hospital is a business with a bottom line.  Yes, most are "non-profit," but what does that actually mean.  Nothing.  It is a complex operation that pays its executives well, with the CEO's of major hospital systems easily earning seven figure incomes, not to mention the associated perks.  Many have a horde of vice-presidents (I recently counted the number of VP's of a major New York hospital system and was quite astounded when I reached 70 and hadn't finished yet!)  Yet these hospitals are extraordinarily dependent on government subsidies and, as Dr. Rosenthal indicates, this striving for luxury may be adding to the already vast cost ($2.7 trillion) of the nation's health care.

Hospitals want (and need) patient-dollars (i.e. government or insurance dollars).  They are in competition with each other and will do what it takes to bring in patients.  Dr. Rosenthal's article concludes with her description of the VIP rooms at the hospital where she trained.  "Though the views were spectacular, the cardiac arrest team could not get there as quickly as it could to the regular wards.  We called it 'a hotel near a major teaching hospital.'"

Going into a hospital? Assess re-admission rates, infection rates, mortality and morbidity rates for various procedures.  Marketing should not be what "sells" hospitals - success of outcome is what should "sell" hospitals. "You have to realize that this is a hospital, not a hotel!"

When Does a Fetus First Experience Pain

An extraordinary discussion is taking place as to when a fetus first feels pain.  At issue is whether pain can be felt prior to 24 weeks of fetal age.  Does it really make a difference?  If one is in favor of abortion, does the fact that that the fetus reacts to pain really matter?  If so, should those performing abortions actually anesthetize the fetus prior to aborting it?  Should the fetus be "put to sleep," so to speak, before the abortive procedure?

Now there is absolutely no consensus as to the exact time when fetal neuronal development matures to the point where pain can be experienced.  Moreover, if one argues that pain can first be manifest at, lets say, 24 weeks, there are invariably going to be fetuses that may have developed this ability sometime before that age, and others sometime after - just as a newborn babies vary in development.  Some babies can sit up at six months, others somewhat earlier, still others somewhat later.  One cannot pinpoint such things!

Believe it or not, there are still those who believe that eight-day old boys undergoing circumcision require no anesthesia as they are "too immature to feel pain."  The circumcision is performed nevertheless - without anesthesia.

For those who oppose abortion the decision is easy.  Whether a fetus does or does not experience pain is not an issue.  Abortion is wrong.  For those who are pro-choice - should it matter?  In a properly performed abortion, any pain that the fetus may feel would be extremely short-lived.  Is this enough to precede the operation with anesthesia?

Doesn't it seem strange to have to anesthetize a fetus prior to aborting it?  

Rivera or "Ree-vey-rah."

A recent story on National Public Radio featured an interview with a superintendent of schools (I do not remember his city) whose surname was Rivera.  I do not remember his first name, but I recall quite clearly that when he spoke, his American English was totally accent-free.  Now I don't know how he pronounces his name, but I'll bet he pronounces it the way I would, or most English-speakers would - the way you would - that is without a Latino inflection or accent.  The reporter of the piece, however, constantly referred to Mr. Rivera as Mr. "Ree-vey-raah" reading his surname with a distinct Latino accent in a way that the name would be pronounced in a Spanish-speaking country.  The reporter, by the way, who, judging by his surname (also not specifically remembered), had a Latino background,  spoke perfect accent-free English, giving a Latino accent only to the name "Rivera" and to his own name in his narration of the piece.

I have never heard reporters pronounce Irish names with an Irish brogue, or Scottish names with a Scottish burr, or German names as they would be pronounced in a German-speaking country, etc.  But this is not the first time that I've noted the exception made for Latino names when uttered by Latino reporters speaking accent-free American English.

I seriously doubt that Mr. Rivera, or other English-speaking native-born Americans with names such as Fernandez or Morales, would actually prefer to have their names voiced as they would be in their ancestral Spanish-speaking countries.

But, maybe they do!  And if so, "mea culpa" (pronounce this in the original Latin manner, please).

Nurse Practitioners Good - Physicians Bad

An internal investigation by the Department of Veterans Affairs has found that one of its hospitals in Jackson, Miss., did not have enough doctors in its primary care unit, resulting in nurse practitioners’ handling far too many patients, numerous complaints about delayed care and repeated violations of federal rules on prescribing narcotics.

The investigation found no evidence that care had been compromised in the primary care unit, the vital first stop for many patients. But it concluded that there were enough problems “to suggest there may be quality of care issues that require further review,” a copy of the investigators’ report says.

These were the leading paragraphs from an article in the Sep 9 NY Times about major problems affecting a VA hospital in Mississippi.  Further along the article goes on to describe other concerns, particularly those regarding a radiologist (a physician, by the way - not a nurse practitioner!) who misread multiple X-rays and CT scans.  A large number of patients will now have to be recalled for re-evaluation.  

With this real issue of medial malpractice, not to mention, complete physician incompetence displayed by the radiologist, I was astonished to see that the opening paragraphs deal not with this horror, but with the fact that many patients, in the absence of an adequate number of physicians in the primary care area, actually had to see nurse practitioners!!  God, how bad is that!!  But then the reporter informs us that there was "no evidence of that care had been compromised....."  Is that supposed to be a surprise??  

This Blog has always been a strong supporter of nurse practitioners.  They are well trained and extremely capable.  It is wrong for the NY Times to highlight primary care by nurse practitioners as a "failure" of care in its initial description of the problems of this hospital.  Care by nurse practitioners can easily be equal to (and sometimes even exceed) that of a primary care physician!!  The major issue of poor quality of care at this VA center wasn't in the area of primary care, but the physician-radiologist - the MD, not the NP!

Reproductive Technology - What is the New Morality?

Reproductive technology is advancing at "the speed of light."  Science has now afforded us the ability to extract the abnormal chromosomal mitochondrial DNA (that part of the chromosome that is responsible for transmitting certain inheritable characteristics) and replace it with the "normal" mitochondrial DNA of a donor egg.  So, for instance, a mom with an inheritable defect transmitted by her mitochondrial DNA can have the mitochondrial DNA of a donor substituted for her own, thereby eliminating the possibility that her child will be subject to some devastating disorder that would have been transmitted by her own mitochondrial DNA.

The child who would be the product of this reproductive technology would, in fact, have the genetic makeup of not two, but three parents - that of the natural mother and father, and that of the donor egg with the normal mitochondrial DNA.

Are these techniques morally justifiable?  How should we react to these feats of genetic engineering?  Such processes are not ones that can be ignored or barred.  We will have to come to grips with a new moral clarity.  The identity of the traditional parent will have to give way to a new concept of "parenthood," and the whole concept of who contributes to the parenting of a child will take on an entirely new meaning.