Solving the Problem, The Battle Ahead
Solving the Problem, The Battle Ahead
(S. Fischbein, MD 11/5/21 Association of Texas Midwives Commencement Address)
When I was a little boy, I had recurring dreams of flying. Running into the wind with arms outstretched and soaring over my neighborhood looking down for the bad guys. Wanting to save the day like Superman. It was a simpler time and like most kids in those days I emulated my heroes. For me there was Thor, with his mighty hammer and Superman leading the Justice League. There was Harmon Killebrew hitting home runs, Thomas Jefferson & the Declaration of Independence. John Wayne, defeating the bad guys and Neil Armstrong taking one step for mankind. I cried with my mother as we buried JFK. And there was my father, working six days a week to support his family. Good strong men all. Role models with an image of God & Country & Family Values. These were the heroes that shaped my youth, imprinting the desire to follow the golden rule.
So were the earliest memories of the medical profession. TV doctors like Marcus Welby, MD. Loved by all and knowing his patients by their first names. And Dr. Ben Casey, fighting the establishment on behalf of his patients. Ethical and dedicated to the core. I even believed Dr. Seuss was a real doctor. But there was also the truth of racial disparities in access and the memory of TV commercials telling us more doctors smoked Camels than any other brand. And we trusted this was true and good without question. Who knew it was a forewarning of the craziness to come? It was an innocent time back then, a simpler time, the bad kids had long hair and blew spit balls. We laugh now but good and evil were clearly demarcated. The national debt was $300 billion and gas was 25.9 cents a gallon.
Today the world you are entering is much more chaotic and complex. Yesterday’s heroes have become today’s villains. Ostracized or cancelled or even erased from history for something they did long ago. The Bible says, “Noah was a righteous man… (then adds) …...in his generation.” There was the wisdom that we should hesitate to hold others to a standard we cannot meet and only judge people by the time in which they lived. Now the Bible is mocked, Thomas Jefferson erased, John Wayne too masculine, Superman disavowing the American way and even Dr. Seuss is now labeled a racist. A hundred years from now will the Obama library be razed because he smoked cigarettes or ate meat? Who are today’s heroes? Who are tomorrows? Will we have any? Sadly, this is the confusion of the world you are inheriting and the one you must repair.
What could be more relevant than how we birth our children? And like so much these days we’ve managed to screw that up, too. You are the future and on your graduation day I entrust to you the task to do better. Because the course we are on is unsustainable. When my kids were growing up, I tried to instill within them my values. I did my best. Just as you have or will do with yours. If my daughter was here today and I asked her, what have I always told her, one thing I am sure she would say is, “Dad that’s easy, Solve the Problem!”.
In the coming years we will continue to have some very big issues in our profession and your generation must answer the call to “Solve the Problem”. Maternity care here in America is not doing well. Identifying the problem is the first step in ever resolving it. But always remember, “Today’s problems were yesterday’s solutions”. At some point in time someone thought the medicalization and dehumanizing of the birth process was a good idea. Too many of today’s issues arose as a result of Stage one thinking (we spoke on this today). Often, but not always, well-meaning souls push for policy because it sounded good or it felt good without ever asking the basic question, “Does it do good?” “Will it work?” “What ripple effects will it have?”
Some examples might include: Sectioning all breeches. Legalizing government unions. Or mass vaccination during a pandemic with an experimental injection.
Our current system of maternity care is filled with stage one thinking put in place by politicians and administrative bureaucrats and ivory tower academicians who have no connection to the actual delivery of care and have lost sight of the individuality of the patient and the purpose of the practitioner. Crushing those who stray from convention to choose a different path. For the best explanation of this I defer to the indomitable Ayn Rand in her book, “Atlas Shrugged”.
How many of you have read this? All of you should! This book altered the course of my life.
One of the characters in Atlas Shrugged is Dr. Hendricks. And his monologue goes like this: (See if it sounds familiar)
“I quit when medicine was placed under State control some years ago. Do you know what it takes to perform a brain operation? Do you know the kind of skill it demands, and the years of passionate, merciless, excruciating devotion that go to acquire that skill? That was what I would not place at the disposal of men whose sole qualification to rule me was their capacity to spout the fraudulent generalities that got them elected to the privilege of enforcing their wishes at the point of a gun.
I would not let them dictate the purpose for which my years of study had been spent, or the conditions of my work, or my choice of patients, or the amount of my reward. I observed that in all the discussions that preceded the enslavement of medicine, men discussed everything except the desires of the doctors.
Men only considered the “welfare” of the patients with no thought for those who were to provide it. That a doctor should have any right, desire or choice in the matter was regarded as irrelevant selfishness, his is not to choose, they said, only “to serve.”
That a man who’s willing to work under compulsion is too dangerous a brute to entrust with a job in the stockyards — never occurred to those who proposed to help the sick by making life impossible for the healthy. I have often wondered at the smugness with which people assert their right to enslave me, to control my work, to force my will, to violate my conscience, to stifle my mind — yet what is it they expect to depend on, when they lie on an operating table under my hands? Their moral code has taught them to believe that it is safe to rely on the virtue of their victims. Well, that is the virtue I have withdrawn. Let them discover the kind of doctors that their system will now produce. Let them discover in their operating rooms and hospital wards that is it not safe to place their lives in the hands of a man whose life they have throttled. It is not safe, if he is the sort of man who resents it — and still less safe if he is the sort who doesn’t.” Ayn Rand 1957
I compel you not to become part of this system. This will not be easy as the temptation and pressure to conform will be great. But to solve the problem we must first identify it. The problem with our maternity system is not because 1-2% choose to birth at home. The problem is the medical model to which 98% of mothers are assigned. The medical model sees pregnancy as requiring treatment and the only result that truly matters is a crying baby in the bassinet. How it gets there is not the system’s concern. Individuals may be good people but it does not matter if the system does not have room for goodness. The striving for perfect outcomes is a fool’s errand. Every one of us will attend our first birth and at some point, sadly, our first loss. The expectations put upon those of us doing the work by those who do not is more than unfair. Midwives and working folk understand this. Demagogues do not.
When former Governor Andrew Cuomo of New York said, “And if everything we do saves just one life, I’ll be happy.” the lemmings in the media cheered. I am certain he had no idea what a foolish thing he said. To live in soundbites is a hollow life. Those in power rarely have self-awareness. They are rarely deep thinkers. The governor’s quote is a perfect example of stage one thinking. I’ll ruin the lives of millions of people, destroy thousands of businesses, endorse people dying alone away from loved ones but look at me, I saved just one life!
I have seen firsthand the problems of the rigid medicalized hospital model as it relates to pregnancy. As midwives you all know what I am referring to. When you have everything needing to follow an algorithm. When every laboring woman must have this or that and any deviation is labeled as noncompliance. The system inevitably fails and what seems like structure all too easily becomes shackles.
Whether the maternity system in its current form can be repaired is doubtful. At some point mothers will realize this and it will collapse and all of you must be prepared to be the creators of something so much better. Standing up for the women we serve will first be met with blistering resistance from those who currently benefit from the status quo. For those with power never give it up willingly. However, those currently in leadership positions will not be there forever. And you as the future leaders must be alert so as to avoid the indoctrination that will be thrown at you. Be courageous. For most leaders are actually cowards. Frightened to raise their heads above the crowd and ask that most brilliant of questions, why? “Why are we doing it this way?” Why is the restriction of reasonable options considered best practices and why so much fear? When you begin to recognize this, you begin to understand the term “political leadership” is an oxymoron. And you will begin to see more clearly the skewing of data. And once you see the halls of academia are built on strawmen you can never unsee it. And with this knowledge you will be freer to serve your clients as nature and morality intended.
Some of you will choose to keep your head down and just do the work. Nothing could be more necessary. But for those of you that choose a path towards leadership or administration, please remember my admonition here this evening. Do not conform to injustice. Alexander Solzhenitsyn said, “The simple step of a courageous individual is not to take part in a lie. One word of truth outweighs the world!” Ahead is a battle worth fighting as childbirth is a rite of passage to be cherished. And you are the next in a long line of the keepers of this tradition.
How we birth matters was discussed in an essay by British obstetrician, Guy Thorpe-Beeston 1998. He said:
“For some women labour is an integral and treasured experience of pregnancy, something to be looked forward to, and achieving a vaginal delivery a life event of enormous magnitude. For others, delivery is an unwelcome bridge that has to be crossed and the option of a caesarean section may appear to be the answer to quiet prayers. The answer must surely be to offer individual choice after appropriate consultation based on existing data, allowing time for reflection before arriving at a final decision.” Seems obvious to us. Not so much to the academic elite.
I presume none of you chose this profession and went through all your training just to follow someone else’s algorithm. You did it for much more noble and personal reasons and I salute you. So, on those stressful days, and you will have them, it is your relationships to your clients and your peers that will sustain you. Do not let the system wear you down. Setbacks do not mean defeat. Our work is righteous and to quote Ennius from 200 BC, “The victor is not victorious until the vanquished considers himself so.” Do not accept an ignoble defeat. The practitioners deserving of respect stand up for their clients. I would rather be cared for by 100 (? #) random midwives in this room than the entire editorial board of ACOG, the CDC and the NIH put together.
We have now identified the main problem, that being the model by which American women are cared for. And we have touched on who is responsible; organized, rigid, academic medicine. So, what solutions do we have to SOLVE the PROBLEM, because, quite frankly, nothing much has budged in my 40 years in the profession. There are no easy fixes but the midwifery model of care was the past and must be the future and we all have to do a better job of letting the women of America know it.
People in touch with reality know what gaslighting is by now. The world is just learning from the COVID debacle what many of us in the maternity world have watched with great frustration. We are told things that simply are not true. But told with such conviction and repetition these falsehoods begin to take on the banner of dogma and reason and become cemented as the norm, the standard. Anyone opposing the policy becomes a pariah to the system. This has to be called out. Ask “Why must my baby go to the warmer?” “Why can’t I eat in labor?”
So much of this gaslighting is a product of the language of the medical model. Solving the problem will have to include reclaiming the language. I’m not just talking about “advanced maternal age or lowish fluid” which is simple sophistry, but also, standing strong that it is women and not birthing people who give birth and breastfeed. Men do not menstruate. These issues may seem trivial but they are a purposeful distraction from the bigger ones. The ones that matter. Stay focused. Avoid the language trap. “The truth hurts” was a common saying when I was young. You do not need to apologize for honesty. Inclusion for all is impossible and actually means exclusion for many. Equity does not mean equally. And judging on merit is not discrimination. We have been too easily cowed by the tiny offended minority who object to truth and common sense. They have no problem calling us names for differing with them. You should not be afraid to use their own tactics in return. Do not be shamed by truth. There will always be someone offended and that’s on them.
Obtuse: Meaning stupid or unintelligent: not able to think clearly or to understand what is obvious or simple. The American College of Obstetrics and Gynecology has become remarkably obtuse. ACOG has joined the herd in putting DEI (diversity, equity & inclusion) ahead of merit and reality. Their agenda focuses here while nearly ignoring a third of all mothers have surgical births.
Again, this is a diversion from the real issues that women need and nothing more. It’s the great Wizard of Oz telling us to pay no attention to that man behind the curtain. We must have truth and bodily integrity or nothing else will matter.
This politically correct idiocy has taken hold in our profession. Conforming to it is not acceptable if we are to give honest and individualized attention to our clients and remake maternity care about caring. Being understanding and sensitive to others does not have to mean compromising your own values or acquiescing to the perversion of language. Beware the smooth talker with phrases that sound reasonable but with a little analysis, are not. Keep an open heart but a focused mind as you go forth into this divided world.
I do not expect everyone in this room to be unified in agreement. That would be ridiculous. Blyss, my podcast cohost, and I sometimes see things from opposite positions but we love each other. So much more meaningful than tolerance! Take the word Tolerance. Sounds sweet. But the word has two definitions. When some use the word, it doesn’t mean acceptance. It means to put up with. To just tolerate something in that manner is belittling and is not compassionate. One thing Blyss and I are in total agreement about is that it’s not our skepticism that should bother anyone but it’s the certainty of so many that should. Beware of the demagogue and their certainty. A confident person knows they don’t know everything and a wise one does not need to insist he does.
Well, that horse is well beaten so let me suggest a few more concrete changes I believe must come if your generation is to see better outcomes and satisfaction.
1) Break the Silos. Meet the condescension of academia towards midwifery & community birthing with kindness and offers of collaboration. Remember that the condescending are so because they are insecure. You will win because you have ethics and reason on your side and realize whatever argument is being made the ultimate decision belongs to the informed individual patient.
2) Eliminate third party payors. Not an easy task, of course. Every layer of “management” (there’s a loaded word) puts distance and hurdles and cost between the practitioner and the patient. It diminishes the individual and makes the system more dispassionate. It dishonors the ethics of informed decision making and respect for patient autonomy. How can we be true to our moral calling when someone else is defining the choices, deciding on the value of your service and punishing those who color outside the artificial lines drawn up by actuaries and executives and risk managers insulated from ever having to face the consequences of their policies? Ayn Rand had foresight. Return to fee for service. A direct exchange between you and your client.
3) Expose and remove conflicts of interest. When doctors and midwives and nurses are employed by an institution to whom is their fiduciary duty? Can they offer options that their institution discourages without fear of retribution? Not likely. Most of you will be employed by someone at some time. Beware of this pitfall interfering with your counseling and decision making.
Bernard Malumud, author of The Natural, said: “We all have two lives. The one we learn with and the one we live after that”. Today you begin to live your second life. Use it wisely.
The official student phase of your career is ending but you will never stop learning. The profession you have chosen, to care for current and future generations, could not be more important. How we birth does matter and we are blessed to partake in this miracle. And the conception, gestating and birth of a new life is nothing less than a miracle. After 40 years I still feel the wonder. We are graced and humbled to witness what so few do. To use your hands…...or not, in the most sacred of ways. To guide your mothers through their rite of passage. Supporting them in whatever way that looks like by individualizing their care and forsaking stage one thinking. By building lasting relationships with these families that matter. For a woman will remember the birth of her baby all her life. Let us all do our best to give them wonderful memories.
You would not be here today without the guidance of your instructors and your mentors. They have made you aware of, as I like to say, what mammals know and so many, including most of the medical profession, have forgotten. We owe these teachers an immense amount of respect and gratitude. They are the bearers of God’s grace and a time-honored tradition. I am honored and humbled to be addressing you all in their presence and in the presence of your families. We all feel great pride in your achievement.
Ghandi said, “A nation’s greatness is measured by how it treats its weakest members.” We have a duty to truth and the protection of those in our charge. My generation has not done well. Yours will do better. Must do better. Go forth and be an example for all of us and for your children and live your next life to its fullest. Be a problem solver. Ask questions. Challenge authority…..do not bow to it. Be your own hero. Do not wait for Superman. He is not coming.
Congratulations graduates and God bless