Throwing the Book at Doctors

By Claudia Wallis

A physician charges that her colleagues treat patients as objects

Michelle Harrison had been a family physician for eight years when she decided to scrap her New Jersey practice and retrain as an obstetrician-gynecologist. The 35-year-old doctor was drawn to the field by the rewards she had experienced attending "home births," by the pleasures of her own pregnancy and motherhood and by her ardent commitment to feminism and women's health. Harrison, who is divorced, searched for a part-time residency that would permit her to care for her five-year-old daughter Heather. She landed such a position at Boston's renowned Beth Israel Hospital, but soon found herself working "60 hours a week in a world in which I do not believe in what I am doing and have grave doubts about what I am inflicting on other human beings."

Frustrated and embittered, Harrison dropped out of the four-year program after seven months. She vents her anger in her newly published A Woman in Residence (Random House; $13.95), blending diatribe with diary notes she kept during her training. At its crux is Harrison's contention that "physicians are trained and conditioned to see patients as objects to be assembled and reassembled."

The conditioning, she says, begins with the total depletion of the residents' physical strength. "Medicine," she charges, "is the only area that doesn't recognize the need for sleep." Her book recounts the horrors of 36-hour shifts, of 30 patient interviews and examinations crammed into two hours, of fatigue so profound that during patient examinations, "I could actually shut my eyes for brief moments while I listened to the patient's heart. . . napping between beats."

For Harrison, the exhaustion was deepened by her responsibilities as a single mother, nagged by worries about child care. Her medical colleagues, she notes again and again, were resentful of her maternal preoccupations and particularly of her part-time status (though she received only half-pay for two-thirds time). "If you aren't willing to give up your child," she was told by a department head at another hospital, "you don't deserve to be an obstetrician-gynecologist."

It is the patient, of course, who suffers when the doctor is exhausted. "When you work 36 hours at a stretch, all you can do is work by protocol," Harrison explains. As a result, she says, doctors railroad patients into procedures and operations without pausing to consider their wishes. She provides numerous examples of this abuse, adding, "Patients have no choice in what is done to them." In one case, a woman's fallopian tubes are tied (a form of sterilization) after she gives birth because her doctor suspects that her uterus is unfit for another pregnancy. He gets her permission while she is half-paralyzed by anesthesia. Another woman is dragooned into a hysterectomy by a gynecologist who refuses to discuss any other options and falsely assures her that "it's just a little operation. [After] a day or two, you'll be bouncing around." According to Harrison, almost every woman giving birth at Beth Israel (which in the book she calls "Doctors Hospital" in "Everytown") is given an episiotomy, an incision that enlarges the vaginal opening. The procedure is not always necessary, and recovery is painful, yet, Harrison charges, most doctors do not know how to deliver babies without it.

It is this interventionist approach to childbirth that enrages Harrison above all else. What she saw at her hospital bears no resemblance to the gradual, intimate, rhythmic process she found so moving during home births. "Childbirth is a surgical procedure," she is told in training. Though Harrison believes that each deli very has its own "natural pace," births at the hospital are expected to follow the contours of an idealized graph of how labor is supposed to progress. When a woman departs from the curve, doctors turn to preordained procedures. They may speed things up by administering Pitocin, a labor-inducing drug, or by artificially rupturing the amniotic membranes. They may order the mother to "Push, you lazy female!" when she does not feel the natural urge to push. And after she has pushed vainly for several hours, they may decide she is exhausted and perform a caesarean section. "We respond to 'maternal exhaustion,'" says Harrison, "when we can't take it anymore."

Exhaustion is only one of many roads to a caesarean. In fact, it often seemed to Harrison that all roads led there. If the mother has not delivered within two hours after her cervix has dilated fully, protocol generally calls for a caesarean or forceps-assisted delivery. If highly sensitive monitors detect "fetal distress," a section is of ten done. If the mother has received so much local anesthetic that she cannot push, she may be cut. Three out of the first four deliveries at "Doctors" in which Harrison assisted were caesareans, though the hospital records show a 19% rate. Doctors like to do caesareans, Harrison maintains, because they are trained "only in modal ities of power and control."

Harrison dropped out of the program in 1979--she now works at a holistic health center near Boston--and wrote her book because "the whole system has to change to be responsive to human beings, and I can't change it from the inside." The book already has ignited sparks among obstetricians. Harrison's contention that there is no humanity in the system is "hyperbole at its worst," snaps Dr. Emanuel Friedman, Harrison's ob-gyn chief at Boston Beth Israel Hospital. Though Friedman expresses respect for Harrison's med skills, he feels that her book describes an obstetrics that is passe. "We've become enlightened," he says. "We do not intervene willy-nilly." He cites a declining episiotomy rate, efforts to control the number of caesareans and a willingness to "allow labor to evolve." This view is affirmed by Dr. Warren Pearse, executive director of the American College of Obstetricians and Gynecologists. The national caesarean rate, says Pearse, is about 17%, and, he predicts, with efforts now under way, "it drop back to the neighborhood of 12% to 15%."

Most doctors will not dispute Harrison's assertion that residents are overworked and overtired, but few feel that doctors are forced to become insensitive automatons. One exception is Dr. Martha Richardson, who was Harrison's immediate superior in gynecology at Beth Israel. While Richardson objects to Harrison's "imflammatory rhetoric," she to agrees that physicians often learn to treat patients as objects. She also points out, as Harrison does, that patients themselves must rebel against such treatment. Says Richardson: "We need a revolution in medicine, but we also need a revolution in the community."

--By Claudia Wallis.

Reported Ruth Mehrtens Galvin/Boston

With reporting by Ruth Mehrtens Galvin

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