The Other Shoe

This Just In: Preventive Worrying Works

I'll have to write more later -- there is lots to tell -- but just a quick entry to let any readers I may have left out there know that Reed was born on Monday, at home, after a long latent but very short active labor.  The posterior presentation didn't make a damn bit of difference in the outcome -- I didn't feel any back pain at all and he came out with just 28 minutes of pushing (longest 28 minutes of my life, but still an improvement over the 53 minutes last time, so I'll take it). 

Both of us are doing great, aside from the whole not sleeping thing, and breastfeeding is off to a good, if painful, start (par for the course for me).  I'll try to post the whole story soon.  In the meantime, here he is just after the birth.  Can you believe his fingernails? 

  

She's Come Undone

I had hoped that if I was blogging with an ice pack in my pants, or, more accurately today, about having recently had an ice pack in my pants, it would be because I had given birth.  But alas, the (evil recalcitrant) baby is still in, and I am just now getting over pain and swelling that required several days of iced drawers. 

You know how when you read the pregnancy books and they list all the fun symptoms and side effects that pregnancy can bring?  And you read over them and think, "eh, none of that sounds so awful"?  And then one day it is?  Yeah.  Let's recap the past several weeks of this pregnancy, shall we?

33 Weeks -- Preterm labor scare, complete with monstrous intestinal emptying, due to bad shrimp.
34 Weeks -- Suspected bacterial vaginal infection, OB's office prescribes topical gel that says in the package insert not to use while pregnant because it could bring on preterm labor, when questioned as to the wisdom of this I am told to use the gel or not treat the infection, but that they won't give me an oral antibiotic at this point in pregnancy; symptoms recede, I decide I probably do not have the infection and gel sits on kitchen counter untouched.  [I later realize that they must have a deal with the company who manufactures the gel.  Lesson: yes, doctors are evil.]
35 1/2 Weeks -- I catch a nasty stomach bug from Casey, spend an afternoon puking my guts (and who knows what else) out and two days in bed with fever and chills.
36 1/2 Weeks -- I suspect I have developed a UTI due to the dehydration from the stomach bug.  I call OB's office so as not to have to spend $50 going to urgent care, they make me come in (which I think is because they are cautious about overusing antibiotics -- HA!) and give me a prescription for an oral antibiotic and tell me I can start taking it before the results of my urine culture come back (negative).  I hold on to the scrip so that I'll have the abx in reserve for the next time I actually do have a UTI.

This brings us to 38 weeks, last Tuesday to be exact.  I get up to go to the bathroom and do not leave the bathroom for four hours, during which time I experience delirium-inducing pain, loss of emotional control, loss of any sex life I may have wanted to have with D after this damn baby comes out (due to the fact that he now knows far more about me than any husband should ever know), and a new fear of latex gloves.  I will spare you any additional details but implore you all to never, ever ignore periodic constipation during pregnancy (or any other time for that matter), as it can get bad enough to require the kind of self-help that no one ever wants to provide for themselves or anyone else. 

The good news is that I only had a few BH contractions during the whole ordeal; if I had gone into labor on top of the misery I was already experiencing, I would have found some way to off myself.  The bad news is that it introduced trauma into an area that will see more trauma in the next couple of weeks, and trauma on top of trauma is not a good thing.  I had a talk with the baby to tell him that he couldn't come until his due date because I needed time to heal.  It took three days to get things under some semblance of control, with the combined efforts of over the counter substances and various new foods. 

But the fun never ends around here, you see, and that's why the new, 39 weeks concern is that this baby is persistently posterior.  Oh, I've known it for a while:  all the movement is in the front, my midwife has felt him to be hiding out in the back and has remarked on it before, encouraging me to get down on hands and knees, blah blah blah.  I checked out the spinning babies website and decided that since 87% of posterior babies turn during labor, it wasn't something to spend a lot of time worrying about.  But my midwife got this deer in headlights look on her face at my last appointment, noting that his head is pretty far down in my pelvis (which I also knew, and had been pointed out before -- he's been pretty low for weeks).  In fairness, she looks like a deer in headlights much of the time, but this appointment has really pushed me over the edge.  For my 37 week appointment, I saw her assistant K, who I really like a lot, and K was very positive when I expressed some of my fears about this birth to her.  Her optimism was just what I needed to hear, and I left feeling brave and empowered. 

My midwife, on the other hand, is unduly pessimistic.  She was much more negative than even the freaking OB during my preterm labor scare, didn't think I would make it too many more weeks.  Now here I am at 39 weeks and no signs that labor is imminent.  She's been harping on this posterior thing for three weeks now and seems very worried that the baby's head is so low, and I'm like, what the fuck am I supposed to do about it?  I feel blamed and defeated before I even get to the point of being in labor -- not a good mental space to be in for something that is largely a confidence game.  If she doesn't believe in my ability to do it, how the fuck am I supposed to believe?  Hence, I don't.  I'm questioning my ability to tolerate back labor and wondering whether I just shouldn't eat the $3500 loss, call the OB's office, and schedule my c-section like a good little fascist. 

Moreover, I'm angry at the baby for being turned the wrong way and causing me more pain and probably an unsuccessful birth story that will dog me for the rest of my life.  I am not a creature who is built to survive adversity.  If this ends badly, as it seems right now that it probably will, particularly if ending badly also means an unsuccessful attempt at breastfeeding, I will never trust my body or my self again.  I'll have unresolved feelings of hostility toward the baby -- who frankly right now I'm wishing I had never conceived to begin with -- and toward myself, develop postpartum depression, and not be able to be there fully or well for my kids. 

I know now that I'm nothing but a natural birth poseur.  I was lucky last time to have had an easy labor, relatively speaking.  I'm not up for anything truly challenging or painful.  Maybe if I had a birth attendant who believed in me things would be different.  I don't understand how someone who has spent the past 30 years trusting the birth process and helping mothers birth their babies can be so fucking pessimistic.  Jesus, you'd think she was a fucking doctor.  So now not only do I not trust myself, I don't trust her either.  And the whole point of having a midwife was to be able to have a birth attendant I could trust.

So, yeah.  Not in a good place right now.  I'm pretty much falling apart at the moment, knowing that I'm getting closer and closer to something that I feel utterly unprepared for and unable to do.  Goddamn fucking baby.  What was I thinking?  I have one perfect child.  Why did I tempt fate by doing this again?

Unity in Diversity

Unless I am just a cranky old woman in a 33-year-old body, there is a certain rigidity that comes as a part of getting older.   I was thinking the other day about why it seems so much harder to make friends now than it did ten years ago, and I realized that it was because I was once open to a lot more diversity than I am now.  I'm still open to diversity in theory, but in practice, my sieve has much larger holes now than it once did.  It's not that I bear ill will against people who are different from me, particularly, but that it is much easier to shut down and dismiss them.  My mental filters have become more refined, if you will.  I don't think this makes me a better person, but I cannot deny that it has happened and will take a new commitment to openness and the force of will to overcome it.

The first day I drove up to my midwife's house, I parked behind a car that had bumper stickers that said:  (1) "Government is the problem, not the solution"; (2) "I'll keep my guns, money, and freedom -- you can keep the change"; and (3) "Eat local."  I saw the same car there the second time I went, leading me to believe that it belonged to someone who lived there (I now know it's her son's car because I recently saw him in it).  I was a tad alarmed; was I in the wrong place?  Would my midwife or her family be offended by my Obama bumper sticker?  When I saw all the framed scripture prints on the walls (okay, just a few, not over the top or anything), my eyes got big again.  So they were religious.  Was I in the wrong place?  Would they be offended at my lack of religion?  Would there be a prayer at the birth? 

I knew I was being silly by thinking these things, but I couldn't stop myself.  My world, I realized, had gotten so narrow -- as, in fairness, have the worlds of many, many Americans these days -- that I was a little weirded out by developing a relationship, even a business-centered one, with someone I knew might have some major differences with me. (For the record, none of this has ever come up, nor do I expect it to).

What threw me even more for a loop, though, was the fact that I perceived the differences to be inconsistent with the commonalities -- in other words, I scratched my head over the "Eat local" bumper sticker, because didn't one have to be on the left to support eating locally?  My midwife's written materials used the term "herstory," which I perceive to be an explicitly feminist term and one generally associated with left-wing feminist academics -- yet she was clearly Christian, which in my mind meant on the right and therefore not feminist (although I have good friends who are Christian and left, so it's not like I don't know that combination and any other is possible).  

When my midwife invited us to a picnic she was having for all of her current and former clients, I spent hours wondering what kind of people would be there (when I asked her what her demographic was, she said it ran the gamut "from rednecks to professionals," lol).  Who are homebirthers, anyway?  I wondered.  Initially I had thought they must all be kind of like me, but after some exposure to the mothering dot com message boards, I started to get the impression that there was a large deeply religious contingent -- I mean even to the point of Christian head-covering women -- but that at the same time, there was a constellation of common threads among almost everyone, including breastfeeding, cosleeping, cloth diapering, anti-circumcision, and selective/delayed/no vaccinations.  I was perplexed.  How could people who in many ways must be very different from me have come to more or less the same constellation of parenting choices?  I even started a thread to ask other homebirthers what they thought about who homebirthers are, and I got lots of interesting answers.  There were people on both the left and the right (though I would say generally libertarian right rather than Religious Right).  There were mothers who were committed to green living and others who admitted to using paper plates, homeschoolers on the one hand and WOHMs on the other.  The common thread really was natural birth and breastfeeding -- beyond that there were no guarantees of sameness.  I puzzled over this for days.

Yet the answer is obvious:  My categories are too simplistic.  People are more complex than I have been giving them credit for.  It has been humbling to realize that the mental shortcuts I've been using to size people up have more than likely been making my world too narrow and kept me from seeing things as they really are.  

In part, this realization comes about because of a seismic shift in my perception of what is most important about me.  The shift has been gradual, but significant.  Whereas I once defined myself through politics and ideology (and relatedly through education and career), I now view being a mother as the most important part of my identity.  I perceive this as a natural response to entering a new stage of life and don't see it as problematic.  But it does mean that my axis has changed, and with it my way of evaluating my commonalities with and differences from others.  That doesn't make me any less rigid or judgmental than I've ever been, it just means that the things I'm most rigid and judgmental about have changed. 

I'm concerned about that too, my judgment stuff.  But I'm taking this one step at a time.  I hope that some of these realizations eventually will help me grow into a person who is more open to listening to others and not taking differences to heart as much as I am inclined to.  But that's a whole self-improvement project of its own.    

More on Health Care, Plus Boring Pregnancy Stuff

I realized after I published the last post that I hadn't been able to cover everything I think is important for optimizing health care.  Coincidentally, I found these two articles in the New York Times, which kept me thinking about how to connect all the dots as I see them.

To address the first article:  Another reason for overutilization, beyond patient preference or doctor greed, has to do with the high level of impersonality that exists in most health care situations.  Some of this can't be helped -- people move a lot, so they change providers a lot, and that's not likely to change anytime soon.  Ideally, we would all have one doctor who knows us well and sees us for many years.  But even in the absence of that, the consequences of high turnover could be ameliorated by spending adequate time, and having adequate communication, with patients.  The fact that medicine has become a volume business is tremendously detrimental to the quality of care provided because it limits the amount of time doctors spend listening to their patients and promotes one-size-fits-all testing and treatment regimens.  This causes overutilization, but it also cause doctors to miss things they might have seen had they been able to truly communicate with their patients.  In so many areas of health, there is a wide range of normal:  for (one oversimplified) example, one person's normal blood pressure may be 90/60, while another's may be 120/70.  Looking at one reading in a vacuum without knowing what is normal for that individual will not give enough information to be able to make a correct diagnosis.  

In addition to lack of time, it seems to me that there is a lack of trust, deserved or not, with which doctors approach their patients.  I call it the "lowest common denominator" syndrome.  Because the doctor doesn't know me, she doesn't know that I take responsibility for my health, do my own research, stay reasonably informed about any health issues I am dealing with, and have a pretty good understanding of what is and is not normal for my body.  I don't know what proportion of patients are like me; I concede that it might be small.  Nonetheless it seems insulting and dismissive for a doctor not to listen or give credence to what I am saying about myself and my symptoms just because they also deal with many patients who are disconnected from their bodies and don't concern themselves much with their health.  So let me clarify that I did not mean to suggest in my last post that most people who go to the doctor with a symptom are crazy hypochondriacs who need to be sent home.  I believe that patients should be listened to and treated with respect, and that if they were, doctors would be able to provide higher quality care because it would be personalized rather than assembly-line.  In a situation that might first appear ambiguous, asking more questions and listening to what the patient has to say will often yield a more precise read on what's going on. 

In some cases, a symptom that could be serious will turn out to be nothing, as occurred with my preterm labor scare.  In the midst of what was happening, I did my internal detective work and my internet research and reached the conclusion that I was not sure what was happening, but that it might possibly require medical attention.  I was always open to the possibility that the problem would pass on its own, but I thought the safest course was to have it checked out.  The nurses at the hospital didn't understand why I was there because they weren't seeing contractions on the monitor at the time I was attached to it.   It was like they didn't hear anything I said about what had preceded my coming in and could only hear what the machines told them.  Even though in that instance it so happened that what the machine was saying coincided with reality, I couldn't help but feel that I wasn't heard or my concerns respected.  But that could have been remedied with words, not the unnecessary fetal fibronectin test that was performed while I was there.   Insurance couldn't have been billed for the words, though.  Money is still, one way or another, the crux of the problem.

With respect to the second NY Times article, it sort of picks up where the first one left off.  Although I don't think that patient-centered care should extend to the point of allowing a hypochondriac as many unnecessary tests or treatments as he or she wants, because that affects the costs in the system as a whole unless the person is paying out of pocket, I do think that a patient's goals and wishes for herself should be taken into account.  I followed with great interest the recent story of the 13-year-old boy who was facing court-ordered chemotherapy, and it made me cringe.  The idea that the state can strap you to a gurney and pump such powerful drugs into your system against your will is more than a little frightening.  I understand that the boy is a minor, and that that is the only reason it was an issue at all, but the fact that a lot of people seem not to think twice about privileging the goal of the state over the wishes of the patient is disturbing.  I would not have wanted to be the judge in that case, that's for sure, because I can see both sides, and it's a tough call.  Still, an adult can decide that he would prefer to die or take his chances with alternative treatments, and it's important that that choice exist.  Living as long as possible irrespective of quality of life, dignity, and other factors is not everyone's goal, and we need to respect that people have different goals for their health care and recommend treatments with that, and informed consent, firmly in mind.

Like the doctor says in the article, people do better when they feel empowered rather than helpless.  This is why having choices is so important.  An unpopular choice may still be the best choice for the individual, and may still produce a similar outcome to or better outcome than the more popular choice.  For myself, I am very happy with my decision to plan a homebirth with my midwife, who I like more each time I see her.  Each appointment takes about an hour, as I come in with a long list of questions and have the time I need to tell her about my history and what's going on in my pregnancy.  She evaluates me as an individual.  I always have choices and am never pressured.  I am fully a partner in my care and am trusted with responsibility to monitor my own symptoms and well-being between appointments -- which I'm highly attuned to.  When I tell her something, she believes me.  I trust her not to push me into any unnecessary testing or treatment, but at the same time, I trust that she is carefully screening for any potential complication that would require the attention of a specialist and that she will continue to do so throughout the labor, birth, and postpartum period.  I feel safe in her care rather than anxious and fearful as I would in a hospital with an OB and L&D nurses who I could never completely trust.  This is not the right choice for everyone, but it is the right choice for me.  I am actually looking forward to my birth this time!  I am not afraid.  

It will be interesting, assuming the birth goes off without a hitch, to introduce the idea of out of hospital birth to our families.  I think D's family will be more open to it than mine, in part because the perceived dangers mostly affect me and I'm not their blood relative, but also because both his mother and his sister have had unmedicated births, and his mother is very much from the less-is-more school of thought and doesn't have much to do with doctors.  My parents are a bit more mainstream, plus my mother is a born worrier -- even worse than me! -- and more risk-averse than I am, if that's possible.  She would never dream of going outside the box for anything in life, much less anything medical.   We're not telling them ahead of time because we think it will be easier to digest once it's a done deal.  

On the pregnancy front, I'm 35 weeks and everything is going very well.  I am getting more and more uncomfortable being so big, but I'm amazed by how healthy I look and feel just by eating a healthier diet and exercising.  I am hugely pregnant, but it's ALL in the front -- the rest of me looks pretty darn good.  And I feel so much less tired than last time at this point.  I found my recovery last time to be pretty easy, but I can envision it being even easier this time around.  I am finding that I'm getting tired of being pregnant already, so it wouldn't bother me if this baby decided to make his appearance before 40 weeks -- as long as he doesn't come on July 4, because I don't think I could take many choruses of "Yankee Doodle Dandy" before smacking someone.     

I guess I'll append my pregnancy memories onto this post since I'm already here and still awake.  Mainly I just wanted to record a few things, like that I got stretch marks much earlier this time, though in a different place on my belly than last time.  There's a small crop of them right around my belly button that I've had for many weeks, though I don't seem to be getting any others (yet -- there's still time).  I think the round ligament pain is probably equally as bad as last time -- it hurts to put on my underwear, lol.  So far the varicose veins in my right leg have threatened to make their appearance and give me pain, but haven't gotten all the way there.  Also, swelling has not been as frequent, probably because I know how to head it off.  Heartburn and reflux are practically nonexistent, which is quite a relief.

I have outgrown most of my maternity clothes -- I am fully in yoga pants now and will stay there for the remainder.  I bought two pairs of the same pants at Target and wear them to work every day -- they are cut loose so that they can almost pass for regular pants from far away. Many of my tops are now too short and ride up, showing a white patch of belly above my pants unless I'm diligent about pulling them down.  Ug. 

Baby is moving all the time, and violently.  Sometimes I utter an involuntary "unhh!" when he gives me a particularly hard kick.  I am constantly attuned to his movements, since my one remaining worry is stillbirth.  We're at the stage where you can see him move through my shirt.  He is safely head down and that's unlikely to change, but he is posterior much of the time, which I'm trying not to worry about too much (as most babies turn anterior either before or during labor).

Not that we were going at it like newlyweds before or anything, but we did decide to forgo sex (and all orgasms for me) until 37 weeks since my cervix is at least partially effaced.  Poor D.  The last weeks of possibility and we can't go there.  I mentioned to him once (only partially joking) that I wasn't sure how people have a third child, because it's hard enough to find time and opportunities for sex with just one.  Plus he's staring down about a six-month drought after the birth, if this time is anything like last time -- breastfeeding hormones do a number on the sex drive.  He is a trooper.  

It is amazing what having so much extra fluid and blood volume in your body will do to you -- I'm having a hell of a time climbing stairs and have been for a while.  As for my walking speed, it is laughable.  Little old ladies can easily lap me. 

That's all I can think of for now.  I'll keep all three of you posted.  :)

P.S.  Guess I wasn't the only one wowed by the New Yorker article.  It will be interesting to see whether additional research substantiates the overutilization theory.  My guess is that it will, but we'll see.

On Haircuts and Health Care

I discovered the other day when I went to get my hair cut that I am an outlier among women who get their hair cut.  Or at least that's how I was made to feel.  I also rediscovered that one of the primary incentives that capitalism provides is for people who sell things to try to sell you shit you don't need by making you think you need it. 

I'm not much of a girly girl.  Yes, I keep my toenails polished in the summer and occasionally apply lip gloss, but that's about the extent of it.   I rarely wear jewelry anymore, and I waver between not caring what I look like and just putting a little powder on so I'm not shiny and being appalled enough to apply real makeup (hint: not caring usually wins that battle).   I buy my clothes at Target and Old Navy for the most part.  I like to feel as though I look presentable and that my clothes are flattering, but I'm not a clotheshorse.  I wear the same shoes every day -- black flipflops in the summer and black loafers in the winter -- because they are comfortable and go with everything.  I cannot be bothered to decide which shoes go with what. 

Part of not being a girly girl for me is that I do very little to my hair.  As in, I wash and comb it to get out the tangles, and other than putting it back with an elastic band after it dries, that's pretty much it.  I was always like this, even in high school (except then we used scrunchies -- remember the scrunchy?).  I have never regularly blow dried my hair or used styling products.  The few times I have gotten a higher-maintenance cut that required styling, I tired of it pretty quickly.  So I have settled on requesting a low-maintenance cut whenever I get my hair cut, and that's about . . . once a year. 

The stylist tried not to let her mouth hang open when I told her how frequently I darken the door of a salon.  She asked me why with a quizzical look.  Then I got the whole battery of questions about what kind of shampoo and conditioner I use (that would be Head & Shoulders and none, respectively), and the lecture about how important it is to use conditioner.  Then I counted the products she used as she styled my hair (impressively, she kept it down to two, so that makes only four products total used including the shampoo and conditioner.  That's three more than I'll be using, but whatever).   She was very nice, gave me the cut that I asked for, and did a good job.  I left her a ridiculously large tip.  After all, I get my hair cut once a year and don't buy "products," so I can afford to be generous.

After the haircut, it was time to go to my final OB appointment.  I was curious to meet the fourth of the five doctors and compare her to the others, plus I needed to ask them to please copy my lab records, which were not in the sheaf of paper that was sent to my house the week before.  I'm always so nervous about these appointments.  I make up lists of questions in my head, have mental arguments with the doctor for days before, and then in the end toy with the idea of not asking any questions or saying anything and just nodding and smiling as if I am one of their "normal" patients.  What actually occurs is always dependent on how comfortable the doctor makes me feel.  If she seems open, I do ask (polite) questions.  You know, just to see what they'll say.

And so it was with Dr. F.  She was incredibly nice, open to my questions, didn't rush me, and didn't seem at all threatened or defensive.  Having a second good experience talking to an OB finally put things into perspective for me:  if I needed the skill set of an OB, I would be happy to have Dr. F as my physician.  But at the moment, there is no indication that I will need those skills.  Moreover, there is a whole other skill set that would be more helpful to me that Dr. F doesn't have.  I knew all this in theory before I went in there, of course -- I've read it in countless places.  But there's nothing like a personal experience to facilitate a deep understanding of the principle that OBs are trained to handle complicated and/or medicalized birth.  Normal birth is not what they do day in and day out, and they know very little about it because they never see it happen.

There are several points from our conversation that I could detail here, but since I'm using this story to get to a larger point, I'll stick to my favorite one.  When I asked about natural childbirth, she asked whether I meant no pain medication (as opposed to a vaginal delivery?  I'm not sure what her mental alternative was).  She said it was fine (um, yeah, duh) and when I probed further, it became clear that she very rarely saw a birth take place without the use of an epidural.  She asked if I had had an unmedicated birth with my first child, and when I said yes, she said that I would have a much higher chance of success then.  Mostly what she sees when women ask about natural childbirth, she said, is first-time moms who end up changing their minds when they are in the moment.  The unspoken postscript was something like, "but there is a small superhuman class of women who are capable of birthing naturally, and if you're one of them, bully for you." 

So, like I said, this exchange really brought it home to me that normal birth is not on the menu for OBs.  It's something you have to special order, and while they may accommodate you, someone in the kitchen is likely to spit in your food because you're considered a pain in the ass for not just ordering off the menu like a good little patient.  Going to a hospital for a normal birth is exactly like going to a fancy restaurant that uses all these shishi ingredients and just ordering a plain salad with lettuce and tomatoes and cucumber.  The ingredients are all there at the restaurant, it's not hard to make, but it's just not part of the assembly-line way they do things to forgo the house-made dressing or the imported goat cheese.  The institutional culture is not friendly to ordering off the menu.  It upsets people's sense of normalcy, or something.  To give a more concrete example, it's like when I used to go to Starbucks and order chocolate milk in the late 1990s (I'm not a coffee drinker).  I have had "baristas" (I can't use that word without irony) give me all kinds of hell, like we don't know what to charge for that, we can't do that, blah blah blah.  I was like, you have milk and you have chocolate syrup, therefore you can make chocolate milk.  As time went on and enough people asked for chocolate milk, they incorporated it into their computerized system and now you can order it with no trouble.  But enough people had to demand it before it became an option they could easily accommodate, even though the ingredients for it had been there all along.  Because not everybody wants a frappuccino or a double this, skim that with an extra shot of the other.  Sometimes you just want plain old chocolate milk.  Which begs the question of why you're at Starbucks ordering that, because it would probably taste better if you just made it at home.  But I digress.

To sum up these three seemingly disparate experiences, I can only say that I have discovered that I embrace the principle that less is more, both as a matter of personal taste and, increasingly, as an article of belief.  (Except when it comes to words -- obviously.  Though there the culture actually seems to be moving the other way, while I am the anti-Twitter).  This is not a popular position in our money-driven, bigger-and-more-is-better culture, and nowhere is that fact becoming more clear than in the realm of health care. 

In the June 1 issue of the New Yorker, there is a fascinating article (available online, woohoo!!)  exploring why health care costs in the United States are so high.  The author visits McAllen, Texas, where Medicare costs are the highest in the country.  He explores various theories as to why this might be the case.  Could the population in McAllen be less healthy than populations in lower cost areas?  No, that's not it; El Paso, a city with a very similar demographic, has Medicare costs that are roughly half of McAllen's.  Could the people of McAllen be receiving better care?  Nice try, but no; the outcomes in McAllen are no better, and in fact by many measures are worse, than those in lower-cost areas.  What about malpractice concerns?  Were doctors just afraid of getting sued?  If that were the case, you would expect Texas' vigorous tort-reform law to have brought costs down.  But it didn't, though the number of lawsuits had dropped nearly to zero. 

No, the explanation for the unusually high cost of health care in McAllen came down to one thing:  overutilization.  Patients in McAllen were given more of everything than anywhere else in the country -- more lab tests, more diagnostic procedures, more surgeries, and so forth -- at a high cost to the American taxpayer, with no evidence that this additional care afforded the patients any benefits and, in fact, plenty of evidence that the unnecessary tests and procedures actually worsened outcomes.

Hmmm, I thought, this story sounds awfully familiar . . .  What goes on in American maternity care is not an isolated occurrence limited to that specialty.  It is, rather, emblematic of what is going on in American health care generally.  The author of the New Yorker article ascribes this disturbing trend toward overutilization of health care to sheer greed on the part of some physicians who see their practices and patients primarily as a revenue stream.  No doubt there are some, perhaps many, doctors who are guilty of having dollar signs in their eyes as they recommend tests and treatments to their patients, and who do not have their patients' best interests at heart.  Some of them are obstetricians.  But, I thought to myself after I finished the article, that can't be the whole story.  It's easy to blame this all on doctors, because if they are the sole source of the problem, it seems eminently more fixable than if we dig a little deeper and realize that doctors couldn't prescribe all of these tests and treatments without patient cooperation.

In my view, it's not just the doctors.  A portion of the blame must fall squarely on the shoulders of the average American citizen, or at least on the structure and culture within which average citizens are operating.  There is an attitude out there, which applies to nearly everything in our lives, that more is better.  More money, more stuff, more food, more house, more car, more everything -- including more medical care.  Combine that with the expectation of an ever-increasing life expectancy and a deep discomfort with the idea of mortality, and you have the perfect storm.  Doctors make more money if they recommend more treatments, yes; but concomitantly, patients have come to expect that if they visit a doctor with a symptom, a test or treatment will follow.  The idea that doing nothing at all might be in their best interest is anathema to the average American.  

I first encountered this attitude during my visits to fertility clinics.  At the first clinic, I immediately recoiled from the doctor who was clearly trying to push an expensive treatment on me that I felt there was no evidence would be either necessary or beneficial (and which turned out not to be necessary).  At the second clinic, my doctor thought it was great that I wanted to give one low-level treatment some time to work before moving on to something more invasive.  "I wish more of my patients were like you," she said.  "Most of them just want to be pregnant yesterday and don't care what they have to do to get there." 

Another example is the overutilization of antibiotics by doctors, including pediatricians.  I have always been from the less-is-more school of health care for myself, believing that most minor illnesses go away on their own and do not require treatment.  I feel the same way about my child's health care; we only visit the pediatrician if we believe that something serious is occurring or that a treatment would be truly beneficial.  The two times that Casey has had an ear infection that was causing him pain, the first time it was not serious but we were nonetheless prescribed an antibiotic, which we decided not to use after it gave him vomiting and diarrhea (a classic case of the cure being worse than the disease).  The second time we asked about ear infections going away on their own and the doctor admitted that 75% of the time they do, but that parents "expected to be given an antibiotic" when they brought their child in.  

Sometimes the doctor drives, other times the patient does.  But both are motivated by the same fucked-up idea:  that more treatment is necessarily better.  And the destination is the same:  higher-cost, lower-quality care.  As the New Yorker article points out, "nothing in medicine is without risks.  Complications can arise from hospital stays, medications, procedures, and tests, and when these things are of marginal value the harm can be greater than the benefits."

The scientific evidence bears this out.  People who receive more care do not do better on any relevant measure (mortality, quality of life, ability to function) than people who receive less, but more personalized, calibrated care from doctors who don't have a profit motive and who are practicing within an organization that places the highest value on the quality of care rather than the quantity.

But as with most everything in America, the profit motive and more-is-better attitude are winning the battle for the soul of medicine.  Changing this will be, to say the least, challenging.  In addition to the expectation of unlimited treatment and testing, there are also structural factors at play that inhibit prevention of chronic disease, which of course would do more than almost anything else to reduce costs.  This was made clear to me when I started eating a low-carb diet and discovered that 85-90% of the average grocery store is comprised of products that are high in refined carbohydrates, i.e. that are unhealthy and lead to diabetes for people at risk (which is, as we get older, most of us).  Same with restaurant menus -- it was like, let me find the two things on this menu that I can eat and choose between them.  The American diet is way fucked up and is making us sick, yet eating healthily is incredibly difficult, especially for those of limited means (see, e.g., Michael Pollan's fabulous book The Omnivore's Dilemma).  So instead we rely on medications to counteract the things we are doing to our bodies with our unhealthy lifestyles.  The attitude is that doctors are there to fix things, not that we are responsible for our own health in any way.  Of course, like I said, there are a lot of structural barriers to living a healthy lifestyle, so all responsibility can't be placed on the individual.  A lot of structural changes are needed.   Health care reform that curbs spending by reducing unnecessary care and eliminating the incentives that bring it about is one of them.