Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
“The consequences of making miscarriage management unsafe will land most heavily on the marginalized and vulnerable. Our appalling maternal mortality rate in people of color will increase by miscarrying while Black. Our country and health care system are rigged to assume criminal intent and withhold lifesaving treatment from these mothers.
The bedrock of my professional relationship with my patients is compassion and trust. I need to be a safe harbor where my patients can share their deepest fears, and I can respond with information and understanding.
Motherhood and miscarriage already carry too much guilt. Our current legal quagmire now also makes them more dangerous.”
Kim M. Puterbaugh is an obstetrician-gynecologist.
She shares her story and discusses her KevinMD article, “Post-Roe, miscarriage is more dangerous.”
This episode is sponsored by the Nuance Dragon Ambient eXperience.
With so many demands on their time, physicians today report record levels of burnout. Burnout is caused by many factors, one of which is clinical documentation. Studies indicate physicians spend two hours documenting care for every hour spent with patients.
At Nuance, we are committed to helping physicians do what you love – care for patients – and spend less time on clinical documentation. The Nuance Dragon Ambient eXperience, or DAX for short, is an AI-powered, ambient clinical intelligence solution that automatically captures patient encounters securely and accurately at the point of care. Physicians who use DAX have reported a 50 percent decrease in documentation time and a 70 percent reduction in feelings of burnout, and 83 percent of patients say their physician is more personable and conversational.
Rediscover the joy of medicine with clinical documentation that writes itself, all within the EHR.
VISIT SPONSOR → https://nuance.com/daxinaction
SUBSCRIBE TO THE PODCAST → https://kevinmd.com/podcast
RATE AND REVIEW → https://kevinmd.com/rate
FOLLOW ON INSTAGRAM → https://www.instagram.com/kevinphomd
FOLLOW ON TIKTOK → https://www.tiktok.com/@kevinphomd
GET CME FOR THIS EPISODE → https://earnc.me/AZvAY9
Powered by CMEfy – a seamless way for busy clinician learners to discover Internet Point-of-Care Learning opportunities that reward AMA PRA Category 1 Credit(s)™. Learn more at about.cmefy.com/cme-info
Transcript
Kevin Pho: Welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/podcast. On today’s show, we have Kim Puterbaugh. She is an obstetrician-gynecologist, and we’re going to talk about her KevinMD article, “Post-Roe, miscarriage is more dangerous.” Kim, welcome to the show.
Kim M. Puterbaugh: Thank you.
Kevin Pho: We’ll get into your article in a little bit. First off, briefly share your story and journey to where you are today.
Kim M. Puterbaugh: I am actually a little bit of an unusual person, in that I am doing exactly what I wanted to do when I was a kid. I wanted to be a doctor. When I was 10 years old, I went to church with my parents and heard a missionary doctor speak about working in Afghanistan, and I looked at my mom and said, “That’s what I want to do.” It took a little bit of time to get there, but I ended up doing exactly what I wanted to do.
Initially, when I went to medical school, I had a National Health Service Corps scholarship. I worked in Appalachia for about eight years, and then I came back to academia and worked at the University of Wisconsin, where I was an associate program director. And then I came to the Cleveland Clinic to be an OB hospitalist, which at that point was a new field. I had always been a generalist before and done full-scope OB/GYN. So I became an OB hospitalist. I had always loved obstetrics, and it’s a newer field that allows people to do obstetrics later into their career.
And then I moved to University Hospitals to become the program director of their OB/GYN residency program. And I just finished up last week as the president of the Society of OB/GYN Hospitalists. We’ve actually become the largest subgroup of OB/GYNs after generalists, so it’s a field that’s really growing quickly but is still pretty young. It’s been an exciting ride getting here.
Real physician voices, twice a week
Free, and one click to unsubscribe.
Kevin Pho: Take us into a day in the life of an OB hospitalist. What’s a typical day like for you?
Kim M. Puterbaugh: In my institution, we work 12-hour shifts. Some people work 24-hour shifts. And so we take care of everyone who comes in the door. If a patient comes in who has a doctor, their doctor may be in surgery, or their doctor may be in the office, and we evaluate them, get in touch with their physician, and let them know what’s going on. Depending on the model, a lot of times we do all the deliveries in the hospital. We supervise midwives, and we work with medical students and residents also.
We take care of all those patients who either don’t have a doctor at all or maybe have a physician in a different hospital system. So we are just the people who are in the hospital, and we deal with normal pregnancies, but then with any kind of emergency that occurs, we’re the backup for all the physicians on the unit. So we get called in for hemorrhages and shoulder dystocias, that kind of thing.
Kevin Pho: So I’m a primary care physician, and ever since the advent of the hospitalist movement, I’m primarily seeing patients only in the office. I rarely go into the hospital to see those inpatients, and of course I leave that to the general hospitalist. Now, do you see that trend also being replicated in the field of obstetrics and gynecology, where eventually they’ll have one group of obstetrician-gynecologists in the hospital and another group who just practices in the office?
Kim M. Puterbaugh: That is the thought: that the GYN subspecialties will be one area, the office will be its own sort of specialty, and then inpatient obstetrics would be another. Part of it is that things change quickly in inpatient obstetrics. Our emergencies occur over the course of about four minutes, so we need to respond really quickly. So the days when I used to be in the office and get called and have to run across the street to the hospital and run up three flights of stairs, and that kind of thing, just aren’t really considered the standard of care anymore. So being on site and really being the leader on the unit is a trend going forward.
Kevin Pho: All right, let’s transition and talk about your KevinMD article. It’s titled “Post-Roe, miscarriage is more dangerous.” Now, for those of you who get a chance to read your article, just walk my audience through it, and share the story of why you decided to write it.
Kim M. Puterbaugh: I realized when the Dobbs decision came down that the implications were much broader than a lot of people realized. Obviously, abortion is a very hot-button issue, and people have very emotional and personal and religious reasons for their beliefs. But as a physician working in a hospital who deals with emergencies, I realized that the impact of this law was far beyond maybe what people understood.
And so we found that with women coming in with miscarriages now, there’s a lot of uncertainty about what we are allowed to practice as quality medicine. We are required by federal law to practice safe medicine and provide emergency care for everyone who comes into our hospital. So if a mother comes in and she’s bleeding from a miscarriage, or she’s getting infected from a miscarriage, there’s now a lot of confusion about when we are allowed to intervene.
There’s a recent article that came out in what we call the Gray Journal, the American Journal of Obstetrics and Gynecology, about the impact of Texas Senate Bill 8. In Texas, there were two hospitals that observed what happened after that law went into effect, and there was a significant increase in morbidity in mothers who were told that they just had to wait until they were in more danger before we could intervene. So it’s really putting the life of the mother at risk for a pregnancy that’s not viable.
I wanted people to understand that this isn’t just a philosophical issue. This is something that we deal with every day, and every night on call, when moms come in with miscarriages or ectopics, trying to make the right decision for them medically, based on science and evidence-based care rather than emotion and political sound bites.
Kevin Pho: Now, can you take us into that decision-making process? Maybe talk about a real case or a hypothetical case where a mother would come in bleeding, perhaps from a miscarriage. Take us into that decision-making process and some of the obstacles and decision points that you have to face in this post-Roe world.
Kim M. Puterbaugh: An example that comes up not infrequently is mothers who break their water very early in pregnancy, so 16 or 17 weeks. They’re still months away from having a baby that can survive, and once their water is broken, they are at significant risk for infection and, if left untreated, sepsis, which can lead to multi-organ failure and death.
The recommendation in the past has always been to counsel the mom, and if she wants to continue the pregnancy, she has that choice. Or if she wants to terminate the pregnancy at that point to save her life and to preserve her future fertility, she always had that option. Now, if the fetus still has a heartbeat, it is a much more complicated procedure to verify that she qualifies to have a termination of that pregnancy.
Kevin Pho: So let’s say someone comes in the middle of the night and you’re on shift. Who do you turn to to discuss the pros and cons? Take us through that thought process, because you did mention that it’s such a difficult decision to make, and there’s a lot of confusion around it. What would you do in that situation, say, in the middle of the night?
Kim M. Puterbaugh: I want to be clear that in my mind, it’s not a difficult decision. From the day I started this profession, the life of the mother comes first. That’s the absolute bedrock of obstetrics. These political complications make the system more difficult, but in some ways it doesn’t change the equation for me. I still provide the best quality care that I can.
So you look at the mother, you look at her vital signs, you look at the labs. You decide if she’s severely anemic. You decide if she’s infected. You look at the lactate: Is she septic? You look at her fever, all of those things that we all do as physicians. We know how to do this, to determine if someone is stable or becoming unstable. Sometimes we repeat labs, all of the things that we all learned how to do throughout our whole careers.
And if it turns out that we get to the point where we decide that the mother really needs to move forward, and in counseling her, she agrees that she wants to move forward with terminating the pregnancy, that’s the piece where it becomes a little more complicated. That’s the piece where we need to get our administrator on call involved and our legal team involved, just to make sure that our documentation meets the standard that we want for the laws in our current state.
And the laws are also changing. I’m in the state of Ohio, and there are several bills in front of the Ohio legislature which would change what our requirements are. Again, it doesn’t change the federal standard of care, so we’re caught a little bit in the middle. But we do want to keep in touch with our legal team and make sure that we’re compliant as much as we can be, while really putting the health and life of the mother first.
Kevin Pho: Now, are there any cases that you’ve heard of where patients were actively harmed in this post-Roe world because of this additional decision-making process?
Kim M. Puterbaugh: Yes. If you look at the article, the AJOG article that came out of Texas, there was a significant increase in maternal morbidity. I would have to look at the numbers again, but I think it’s in about the 20 percent range of severe maternal morbidity, in terms of needing blood transfusions and IV antibiotics and hospitalization, because of the management of miscarriages that we have been doing. At least one in five documented pregnancies ends in miscarriage. People think that up to 50 percent of all conceived pregnancies end in miscarriage. So this is an incredibly common thing that touches most women in the course of their reproductive lives, and so not being able to manage them as effectively and safely as possible is really a hindrance to the quality of care we can provide.
Kevin Pho: So in practical terms, what kind of delay are we talking about? Because you had to get the administration involved and get the legal team involved. From a practical standpoint, how long does that delay care?
Kim M. Puterbaugh: In our institution, we can do that quite quickly. We don’t have quite the same laws in Ohio that Texas has. It seems from that article that a lot of people were discharged from the emergency room and told to come back when they were having more bleeding or were more infected, and that caused delays of days to even weeks. And that’s the situation where you can get into impacts on fertility and impacts on the mother’s health.
Kevin Pho: Now, is it implied that the medical decision-making then was affected by this law, leading to the advice to perhaps come back?
Kim M. Puterbaugh: Yes, absolutely. There are penalties to physicians for intervening if there’s still a heartbeat on the baby. There’s the bounty hunter aspect of the law, that anyone who aids and abets the termination of a pregnancy can be sued by bystanders, and that sort of thing. So I think it just created a lot of anxiety and confusion in the medical staff in Texas. Fortunately, we don’t have that aspect to our law, but those are some of the things that are in front of the legislature now.
Kevin Pho: Now, off the top of your head, are there any specific cases where there have been some of these consequences against physicians?
Kim M. Puterbaugh: We have not had any in Ohio yet. I think the question is going to come through Texas first, if those $10,000 fines by bystanders will be implemented. It’s really a shocking change to the American legal system, because it’s the first time that the mother has to prove that she didn’t have an abortion, rather than the accuser proving that she did. So it’s a very disturbing turn of events, even beyond the whole abortion question that we’ve gotten thrust in the middle of.
One of the things that I actually have been really proud of with my colleagues in OB/GYN is that it’s really galvanized OB/GYNs to speak out collectively. I think as physicians, we tend to practice as lone wolves. We like to make our own decisions and move forward and make our own treatment plans. But I think this has really pulled a lot of people together to say that this is not appropriate for our patients, this is not the care that they deserve, and to really speak out.
Kevin Pho: We’re talking to Kim Puterbaugh. She is an obstetrician-gynecologist. Her KevinMD article is titled “Post-Roe, miscarriage is more dangerous.” Kim, what kind of advice do you have for obstetrician-gynecologists practicing in this post-Roe world?
Kim M. Puterbaugh: My recommendation would be to practice quality evidence-based care. At the end of the day, doing the right thing is the right thing, and if there’s a law that makes that more complicated, we still owe our patients that duty of care.
I also think, like most things in America, this falls most unevenly on our most vulnerable populations. I certainly think the decision-making process that people make for Black and brown mothers is somewhat different than for wealthy suburban white moms. So make sure that people have access to care and can come back. If you’re sending them home from the emergency department, make sure that they have transportation. Make sure that they can come back in a timely manner, so that they don’t have a really severe complication.
I actually had a patient early in my career who was miscarrying. She was 15. I had a very long conversation with her mom, and we had a plan in place. She was stable, and she was coming in for a scheduled D&C on Monday morning, and this was Friday. We had the whole plan in place. She had all of her warnings in place, so she knew what she was supposed to come back for. And she ended up coming back having really hemorrhaged, with a hemoglobin of five, needing blood transfusions. And I said to her and her mother, “What happened? I thought that we had this plan in place.” And it turned out her parents were divorced, and she went to her father’s for the weekend, and she didn’t want to tell him when she started bleeding.
I think that the people who are the most vulnerable will be the most impacted, and we need to make extra sure that they have access to care when these barriers are in place.
Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?
Kim M. Puterbaugh: At the end of the day, we know how to take care of people as physicians. We know what the standard of care is. I always feel like it’s better to do the right thing and defend that than to do the wrong thing and argue about it later. I think our patients need us more than ever right now.
And there are resources if you are struggling with patients that have septic abortion, which is something we had not seen a whole lot of when Roe was in place. There are resources. The Society of OB/GYN Hospitalists can help with that. We actually did a big simulation to help people know what to do and make sure that women are getting fluids and antibiotics and things in a timely manner to save them. And just reach out. I think the more collective voices we use, the better, and our voices as physicians are the informed ones in this debate. We should be the people making the statements, rather than politicians who really don’t understand the collateral damage that this is causing.
Kevin Pho: Kim, thank you so much for sharing your time and insight, and thanks again for being on the show.
Kim M. Puterbaugh: Great. Thank you so much.
Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
