CAUTION: HEALTH HAZARD is hardly a warning most of us would like to see on the Labor and Delivery Room doors of our hospitals. If there is one thing we as Americans would like to believe of our health system, it is that we are capable of providing safe, progressive care, especially during childbirth.
In "A Woman in Residence," Michelle Harrison poses some urgent questions about the welfare of mothers and infants in our most up-to-date institutions. A physician, Harrison challenges obstetricians and gynecologists on some of the more frequently performed procedures associated with their profession, at the operating table and in the delivery room.
She says they perform unnecessary caesarean sections, episiotomies and hysterectomies, and she offers wrenching descriptions of expectant mothers and of women with gynecologic illnesses who suffer under the knife, and suffer as well from the sometimes mediocre care of exhausted, overworked staff residents and interns.
She tells of her transition from small-community family practice medicine to a year of residency training in obstetrics and gynecology at what she describes as a well-respected teaching hospital. The account of her hospital experience is gripping and graphic. What makes me uneasy, however, is that even as a physician myself, I cannot determine just how much of it is accurate.
Harrison, preoccupied by her hostility to the training system with which she became involved, does not even attempt to be dispassionate, despite the fact that she is writing about issues likely to arouse the most profound vulnerabilities of others. At the onset, her bias emerges in a dream in which "were the faces of prominent obstetrician-gynecologists I had known . . . I knew in the dream that they had planned it all and were going to kill us all."
And it isn't limited to her dreams. Repeatedly, she ascribes outrageous statements to unknown people. A psychiatry supervisor: "Psychiatry is a science. If, in talking, the patient gets better, fine, but that is not your goal. Your goal is to understand how the mind works." A chairman of a department of obstetrics and gynecology tells Harrison, who has a young daughter: "If you aren't willing to give up your child, you don't deserve to be an obstetrician-gynecologist. Dr. Harrison, your problem is that you lack motivation."
She offhandedly quotes one of the surgeons: "In gynecologic surgery, the vagina is defined as dirty." A reader unconversant with the jargon is incensed at the slur. She omits the explanation that the mouth and rectum are also "dirty" because each harbors bacteria that could potentially infect a part of the body not usually exposed to microbes.
These are cheap shots, unnecessary and, unfortunately, too common in "A Woman in Residence." Certainly there are people as insensitive as these in medicine, as there are elsewhere, but is she asking us to believe they were all like that? Since her speakers are not identified or offered the opportunity to defend themselves, how do we know they are being fairly represented?
What grates badly is the blatancy of the encounters she cites and the predictability of Harrison's presentation of herself as a good person and of most other doctors as uncaring. It is unfortunate, because the invective makes less palatable some ideas worth thoughtful consideration.
Many women would be better off getting second opinions about whether hysterectomies are necessary for them. Episiotomies (the cutting of vaginal tissue to prevent tearing during delivery) are not always necessary, and less urgently paced deliveries with massaging techniques might render them even less necessary, decreasing discomfort and the possibility of infections. More judicious use of pain medications and anesthetics which can weaken maternal contractions might help prevent some cesarean sections.
Internal monitors are not always necessary, and may sometimes be misleading. And cesarean sections are done more often than is necessary. But so are appendectomies, and for what is sometimes the same reason. It may be impossible to know if a procedure was needed until after it has been done. Distress on a fetal monitor might mean nothing, but might also mean a potentially fatal knot in an umbilical cord. Who would want her baby to go through a prolonged natural birth before finding out?
It is also true that residents and interns are painfully overworked in many, if not most hospitals, are frequently exhausted and show, as a result, poorer judgment after 36 hours on their feet than they might otherwise. But the simple answers--more staff, shorter working hours--are not so simple. Hospitals are not eager to pass on to patients the additional financial burden of those extra salaries when medical costs are already overwhelmingly high. And surgical residents, scrambling for chances to learn how to perform operations, often complain that there would be too little surgery to go around if more people were hired.
Harrison becomes most appealing in the almost lyrical pages in which she describes the home childbirth experiences of women she delivered before she began her residency. Our instincts, like hers, are that giving birth in a hospital should be just as satisfying. To achieve that end might require retraining doctors in how they look at childbirth. But that requires an open, unhostile atmosphere, one of warmth and respect--an atmosphere unfortunately lacking in much of "A Woman in Residence."