Amy Tuteur calls sexual exploitation “the most egregious violation of professional conduct that any obstetrician-gynecologist can commit.”
And in that context, she details an interesting scenario brewing in California. Stuart Fischbein is an obstetrician that’s widely hailed in homebirth circles, writing a book and being a foremost advocate of homebirths.
Unfortunately for him, he also exercised some poor judgment, as detailed in this newspaper report:
He called her “sweet pea,” held her hand and warned her about moving too fast with her fiancee. What began as flirtation morphed into an affair that was twice consummated.
Even before the relationship dissolved into angry phone calls, a lawsuit, a criminal complaint, therapy and wounds that changed lives, there was a problem.
He was her doctor.
He’s calling on his most ardent supporters, homebirth proponents, to help fund his legal defense fund, which he needs as he’s facing a revocation of his hospital privileges. There’s some cognitive dissonance here, as Dr. Tuteur observes, asking, “Is homebirth so important that any doctor who supports it, even one who has acknowledged sexually exploiting a patient?”
Indeed.
Related posts:
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- A doctor who advocates no screening tests
- Adopt a Doctor: Support Their Income
- Sued for being late to a delivery
- Is an efficient physician necessarily a good doctor?
- Should a doctor be banished from medicine after having sex with a patient?
- Doctor flying Southwest, jailed for trying to use the bathroom
{ 23 comments }
Based on what I’ve seen of OB’s (at home and on the road in my storied past), the sad fact is that once he loses his privileges at this hospital, there will be another one somewhere (probably in the sticks – where the news still comes from a weekly paper) that will scoop him right up.
“Reputation Rehab” comes cheap in specialites that are in short supply – especially those that fill a niche.
Reform anyone?
Poor judgement is wearing white socks with dress shoes. Having a sexual relationship with a patient is a life-style choi…I mean a continuous, deliberate and decietful violation of medical ethics.
Instead of supporting his legal defense financially, homebirth advocates should instead request that he do the honorable thing and resign his medical license.
Last night, the brilliant curmudgeon, Dr. Greg House, broke down and admitted he needed help. This OB needs to do the same. If losing his privileges, his license and his freedom gets him that help, more’s the better.
Facts:
1. It’s hard to find doctors willing to work with midwives to help achieve the low rates of interventions/ Caesarian found in European birthing practice (which is mostly non-medical).
2. One in ten doctors has had some type of sexual relations with a patient.
3. Supporting Dr. Fischbine might help the cause of homebirth–and will likely not change the rate of doctor predation on patients.
4. The utility calculus seems clear.
“It’s hard to find doctors willing to work with midwives to help achieve the low rates of interventions/ Caesarian found in European birthing practice (which is mostly non-medical).”
That’s not true at all. Certified nurse midwives are fully integrated into American obstetrics and attend a substantial proportion of vaginal deliveries.
American homebirth midwives are a second, inferior class of midwife (certified professional midwife or lay midwife) with less education and training than midwives in Canada, the Netherlands, the UK, Australia, indeed ANY country in the industrialized world. The reason most obstetricians will not work with them is because they are grossly undereducated and grossly undertrained.
Whereas midwifery is a master’s level degree in the US and a university degree in all other first world countries, the CPM is a post high school certificate program that includes “courses” such as “gem energy” and “flower essences.” Dr. Fischbein supports these midwives and they support him in return. Evidently a little thing like being a sexual predator doesn’t interfere with that support.
“One in ten doctors has had some type of sexual relations with a patient.”
Wow, that is a stunning statistic. Could you please provide the source of that information, Skeptikus, so that we can learn more about this?
Dear Amy,
1. I’m afraid you don’t know much about midwifery. CNMs frequently work in homebirths. All three of my children were delivered at home with CNM’s. Why are you disseminating disinformation about CNMs, who have every bit as much education as their European cohorts? What’s your agenda?
2. While OBs may hire CNMs, very few will partner with them, i.e., allowing CNMs to have their own practice and only assisting when the CNMs say so. In my homestate, there are only 4 such practices. This is essential because ONLY when you allow CNMs authority to you have their benefits of decreased medical intervention.
2. One bit of statistics I could easily find on Drs. and sex with patients.
http://www.bmj.com/cgi/content/abstract/304/6841/1531
“CNMs frequently work in homebirths.”
Only about 4% of CNM deliveries are homebirths.
Interestingly, the neonatal death rate at homebirth with a CNM is double that of hospital birth with a CNM. The neonatal death rate for homebirth with a lay midwife is triple that of low risk hospital birth.
The problem with American homebirth midwives is their appalling neonatal death rate. That’s why they have very few physician supporters. I presume that is why they are willing to overlook Dr. Fischbein’s conviction as he is willing to overlook their high rate of neonatal deaths.
I seriously question the 10% statistic. The article you cite found OBs to have a 4% prevalance and that is for doctors who take care of young, healthy women. For reasons beyond good ethics, I would hope the same isn’t true of geriatricians, critical care physicians, transplant surgeons, pathologists etc.
I found a review article on the issue that looks at many different types of studies looking at this issue:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2720840
Even the lower statistics are still sad.
Dear Amy,
1. First you say “American homebirth midwives are a second, inferior class of midwife” then you say that, well, CNMs are involved in home births. Hmmm . . .
2. “the neonatal death rate at homebirth with a CNM is double that of hospital birth with a CNM.”
That is a vicious slander!!! Where did you get your statistics. The ONLY epidemiologically acceptable study of midwife birth failed to show medical births were in any way superior as far as neonatal deatha to certified PROFESSIONAL midwife homebirths.
http://www.bmj.com/cgi/content/abstract/330/7505/1416
And far superior as far as intervention.
Oh, Amy, I just realized where you got your stats from. The infamous Pang (2002) study. You know as well as I do that that study was thoroughly discredited. Why? It counted out-of-hospital births that had no attendant, and births with unknown or unnamed attendants as midwife births. That’s not kosher, and you know it.
As Sir Walter Scott reminds us, “Oh what a tangled web we weave . . . “
“That is a vicious slander!!!”
Homebirth increases the risk of neonatal death. The only people who appear to be unaware of that are homebirth advocates themselves.
You can find the data in the CDC Wonder database. Dr. Michael H. Malloy, at the University of Texas Medical Branch in Galveston, compared a range of adverse outcomes among infants by delivery attendant type and site of delivery occurring in the U.S. over a recent 5-year period. The analysis was limited to term (37-to-42 weeks), singleton, vaginal deliveries.
The neonatal death rates in each group were 0.68/1000 hospital MD births; 0.5/1000 hospital CNM births, 1,0/1000 home CNM births and 1.7/1000 homebirth direct entry midwives.
Moreover, the study you cite (Johnson and Daviss, BMJ, 2005) also shows that homebirth with a CPM has almost triple the neonatal death rate of low risk hospital birth. The authors, two professional homebirth advocates (Johnson is the former Director of Research for the Midwives Alliance of North America, and Daviss, his wife, is a homebirth midwife), played fast and loose with the data.
Johnson and Daviss claimed to show that homebirth with a CPM in 2000 was as safe as hospital birth, but they compared it to hospital birth in a bunch of out of date studies extending back to 1969. They neglected to mention that homebirth in 2000 had almost triple the neonatal mortality as moderate risk hospital birth in 2000.
All the existing evidence, and all the national statistics show that homebirth with an American direct entry midwife dramatically increases the risk of neonatal death. As I said above, the only people who don’t appear to know this are homebirth advocates.
I am a nurse and childbirth educator who knew enough about the perils of hospital birth to know beyond any doubt that I was safer at home with a CNM.
A hospital, first of all, is rife with infection. My first two children came home from the hospital with nosocomial staph infections. Then there are the unnecessary interventions that fall like dominoes onto vulnerable women.
My last two births were at home. I didn’t do it for the niceties, I chose it for safety. My CNM gave me the best care I ever had in any of my pregnancies. A thousand times more attentive and proactive than any OB/GYN I had seen.
But back to the issue. Should a sexual predator be supported because he is the only one who backs home births? No, of course not. I am embarrassed for the women who are not shunning him.
That said, it points to where there needs to be more support for home births for parents that choose them. If more physicians would open their minds, it wouldn’t boil down to having to support a pervert in order to obtain medical back up. It is appalling that American physicians are so frightened, so narrow minded and, dare I say it, so greedy, that they will not work to create a safe alternative for expectant parents.
Browsing around among BMJ articles, it sure looks like there is some cherry-picking of individual studies to support claims on both sides. The last time I looked at the broad literature was over 15 years ago, at which time the home-birth/midwifery proponents seemed to have the balance of the evidence firmly on their side. I considered that a strong indictment of the scientific discipline in the OB/GYN specialty, who by rights should be vastly safer than home birth.
Doing a cursory search on PubMed just now, it seems that for low-risk pregnancies, home birth has similar neonatal mortality and, of course, lower medical intervention. It’s possible that my search results are anomalous or somehow biased, or that there is some bizarre selection in the medical journals in favor of evidence for home birth.
Has anybody conducted a broad literature search in the last five years, looking at empirical results of comparisons between home/midwife and hospital/MD birth?
“it seems that for low-risk pregnancies, home birth has similar neonatal mortality and, of course, lower medical intervention.”
Those studies come from other countries where midwifery education is far more rigorous than the post high school certificate of American homebirth midwives, and where eligibility requirements for having homebirth are very strict.
Indeed, those studies show that homebirth with an American homebirth midwife has triple the neonatal mortality rate of homebirth in Canada or The Netherlands.
Dear Amy,
I fear you are truly disseminating false information.
First, from an epidemiological perspective, prospective cohort studies are far more valuable than retrospective descriptive. All yr studies are the former, not the latter. The ONLY prosective cohort study so far discussed is the Johnson/ Daviss report.
Second, u absolutely distort their results. They was a slightly higher rate of natal death in the homebirth group–of a few percentage points. If there had been 1 death fewer, the hospital deaths would have been greater. In other words, the rates were ridiculously close on an absolute level–leading to the conclusion that there was no statistical difference.
Third, you vicious, ad hominem attack on Johnson/Daviss is absurd. By your logic, no OB study would be credible because OBs have an interest in keeping their turf.
Third, do you have a citation for the Malloy study–has it been published in a peer reviewed journal. I’ve worked with CDC data. IT has the same problem as the Pang data–groups all home births (including accidental ones) together. And, again, it’s a retrospective study–kind epidemiological sludge.
Amy, you are a doctor. You are granted great privileges and wealth by the state in the hope that you will use your status responsibly for the benefit of all–not just the financial interest of your profession. Please remember that next time you post something publically!!! All the women who have been cut and mangled by c-sections, contracted hospital-borne infections while giving birth, has unnecessary episiotemies–or more broadly died from OB-transmitted puerpel fever–would want you to remember that too.
Second, your outrageous claim “American homebirth midwife has triple the neonatal mortality rate of homebirth in Canada or The Netherlands”
Looking at the Johnson/Daviss study and having nothing to do with ob, home birthing, women’s health etc. personally, I think it’s a poorly designed study. In the first place, It’s not a true cohort or prospective study at all. A prospective cohort would identify both the cohort and the intervention groups initially and then follow them through time. In this study they identified a group of patients that were going to undergo homebirth only. They then compared that data to other registries that had been collected in the past to compare rates of medical interventions. While this might be acceptable for inital hypothesis gathering studies it is no way a gold standard “Prospective Cohort” that skeptikus is claiming.
I’m also concerned about this statement:
“the North American Registry of Midwives made participation in the study mandatory for recertification and provided an electronic database of the 534 certified professional midwives whose credentials were current.” Does that mean that they were required to participate in this study in order to have a job? It’s unclear to me from the text but if true that would be a major breach of research ethics where dispassionate objectivity is vital.
I’ve been very disappointed in the quality of publications from the BMJ over the last 5 years and approach any paper published in it more cynically than others. That’s my personal bias.
I will admit that I don’t know much about this issue and, not to be rude or dismissive, I really don’t care. (I’m sure most of you don’t care about ANCA vasculitis
) I say that to mean I’m not trying to get into an argument one way or another, I just take issue with poorly designed studies being misrepresented as other than what they are because that makes for those observers like myself to really be able to trust the positions being put forth.
Oh, and I think you meant “libel” not “slander” earlier.
These responses are fascinating. What a dramatic example of how polarizing and volatile the issue of home birth is! Almost none of the responses address the original question.
The comments also demonstrate the fear and misinformation that accompanies almost any discussion of home birth with a physician. Home birth can be so safe with the proper skills and preparation. Yet most doctors respond almost hysterically in opposition. Because home birth is a viable alternative, I can only conclude the rage is based on economics and potential lost income.
And by the way, there is no such thing as what Dr. Tuteur refers to as an “American homebirth midwife”. There are CNM’s and there are lay midwives. Most, if not all, states, in response to intense pressure from the medical profession, no longer qualify or recognize lay midwives. There are many lay midwives who now practice underground because they have no recourse to legal status. This in itself does a tremendous disservice to birthing women. Lay midwives with appropriate training and supervision can be excellent birth attendants. But with no regulation you have a mixed bag, with some very dangerous people indeed doing damage out there.
This is definitely an area that needs more exploration and civil, reasonable discussion among professionals who need to respect each other, not deride each other. That should be easy if we have nothing but the safety of mothers and babies at heart.
But if it is something else driving the animosity, that sort of impartial dialogue will never happen.
Dear Nuclear fire,
Surprise–the Johnson-Daviss study is not perfect. One cannot make up perfect data if they don’t exist. You do the best with what you have. The Johnson-Daviss is among the best we have–and is not so methodologically horrible that we can just disregard it.
What does Tutuer cite to discredit it . . . . the execreble Pang study and some unpublished searches on CDC databases?
Given that no credible empirical evidence establishes clearly the superiority of one method over the other (as far as neonatal, perinatal mortality) but ALL studies show dangerous medical intervention are lower with home births, why does Amy Tutuer demonize the home birth advocates? Home birth seems a reasonble reaction to the evidence we have
So per Dr. Tuteur’s followup, the best evidence against home birth is a rather arbitrary comparison of one study’s mortality figures, with unrelated studies form other cultures and medical systems. So perhaps nothing has changed since I last checked 15 years ago: home birth was at least as safe as hospital, and arguments to the contrary were based on cherry-picking and rumors of unpublished results. This is where medicine still falls considerably short of being a truly scientific discipline.
Wow, as a midwife, I have several thoughts about the original question and the subsequent comments. To the original issue, I don’t know specifics on this case but “IF” the man is guilty I do not support him. I only say “if” because there must always be a presumption of innocence until proven otherwise. That said, I shudder to think I’d ever be so desperate for medical “back-up” that I would risk putting a woman “in harm’s way” for any reason. I realize that Dr Tuteur may believe I would because I attend and strongly believe in home birth for normal women experiencing normal pregnancies. I’ve read her statements before and have no desire to debate her on this. I know it won’t help anyone and I am suspicious of the vehemence displayed in her opposition to homebirth. I don’t believe the debate should be whether home birth is safe but rather is hospital birth safe? I have been a nurse since 1983 and a CNM since 1992. I’ve worked in several different hospitals across the country and worked as a CNM in all practice settings-hospital, birth center, and at home. I spent twelve years working at Parkland in Dallas as a CNM so I’ve caught more babies than a lot of OB’s in practice. Through the years, I’ve seen problems in every setting. I know there are great doctors, midwives, and nurses associated with all those settings. I am convinced of only one thing-we must ALL begin to work together and share our unique perspectives for the good all women & families. I don’t believe any one thing is good for every woman. I will say that some of the things I saw & experienced at Parkland are still haunting me. The awful way I saw some patients treated, not to mention some residents/midwives, has me wondering if I ever want to catch a baby in a hospital again. There were cases which I believe constituted outright assault but in the usual “conspiracy of silence or gang” mentality it was overlooked and at some level condoned. I have a MSN but started as a LVN, then ADN/BSN, and most recently started work on a PhD. I stopped working on it, while at Parkland, in part because I was too disillusioned to even do the work. I am suspicious of every study I read and not your accepted critical review kind either. I gathered data for several big studies and observed several others while at Parkland and I’m not sure I even believe in research anymore. There were so many flaws, so much imperfection, and such a willingness to accept it that the foundation I was educated on is shaken. I hate to cite studies, for fear they may be like some of those were but what we seem to be certain of is this-US infant mortality is bad enough that we’re tied with Slovakia and our C-Section rate nationally is over 30%. The only thing we seem to be #1 at is spending money and having premature babies-not counting our use of technology. Personally, my hospital births were lousy and one of the great regrets of my life will be never having the kind of birth I wanted-the kind I attend for other women. My daughter paid me the ultimate compliment, and asked that I make sure it was that kind of birth that she got-now twice. I think the “kind” of midwife is a more complicated issue than most midwives want to debate. Parkland has one of the biggest midwifery services in the country but only a few truly believe in birth. Most of them function as some weird morphed physician assistant and that isn’t midwifery I can believe in-and yes, I feel guilty at having been there for 12 years. The problem then becomes about what women think of midwives. I’m sure there are those that celebrate finding a CNM but if you’re worried about staying out of hospital who is most likely to transfer…you can see the problem. My final thoughts are to those having knowledge of home birth, midwives, and the research making comments. To those in favor, I sincerely thank you for both your knowledge & your willingness to speak up-it’s hard out here being a midwife but our allies take a beating too! For those of you against, as you attempt to take me apart as I fear you will, can I say “can’t we all just get along?” I want the best for each woman seeking care and I think you do as well so can’t we agree our numbers are frightening and strive to work together to provide Evidenced Based Care-real evidence that we can all believe in.
Sherry, would any of those flaws be sufficient to materially bias neonatal mortality figures? If so, please specify what and how. I just can’t see mortality being miscategorized as, say, “exceptionally low respiration and failure to thrive…”
I’m a CNM who has had a homebirth practice in Los Angeles. One of the issues that midwives face is the fact that they have to rely on the OK of another professional (a physician) in order to practice. Due to (sometimes) differences in philosophy and (sometimes) social pressure, there were only a handful of OBs in the area that were willing to act as backup for out-of-hospital CNMs or other midwives.
When I first read about Dr. Fischbein’s improprieties I thought about the tenuous situation that midwives find themselves in where, even if they’re impeccably trained and doing everything they ought to do, their practice can be put in jeopardy because some other practitioner sleeps with a patient. The right thing to do is to oppose patient exploitation wherever it occurs, but maybe it’s also time to look at the system. If the state of California has decided that midwives should be able to practice, their practice shouldn’t be threatened by external events like Dr. Fischbein’s misbehavior or the untimely death of Dr. Gregory Dantzler.
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