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Last Word: The last delivery


Excessive malpractice premiums forced this physician to give up the work she loves.



The last delivery

By Carolyn A. Chambers, MD

It's dark, the lights dimmed. The stillness is broken by the fetal heartbeat on the monitor and the mother's measured breathing. She's fully dilated. You sit with gloved hand awaiting the next contraction. You feel the familiar mixture of anticipation, impatience, and watchfulness. It's not your first delivery, or 50th, or 1,000th—it's your last.

Tomorrow you will awake no longer an obstetrician.

The contraction comes. You coach her with her nurse. Push harder. You can do it. As she relaxes, you are left with your thoughts. You return to undergraduate school, to the 1,000 circumstances and minor decisions that led you to medical school. Should you have made different decisions? You can't remember anything else you ever wanted to do.

Another contraction brings you back into focus. One more strong push. You can do it. Almost this time. At this point you can't help yourself. Retrospective self-examination seems inevitable. You regain the train of thought at residency. Lots of tears, frustration with your sudden incompetence. You eventually gained confidence and skill, gathering the tools with which you would practice. You were then cut loose into the world of Medicine.

She's ready to push again. You gratefully refocus your attention. Come on, the head is almost there. One more. She relaxes, and again, relentlessly, your mind drags you back.

You remember the excitement of those early days of practice. It was just like you thought it would be. You loved your work: Every delivery was a joy, every surgery a success. Thank God for that time.

With a wave of nausea, you recall the first lawsuit. You began to question everything—your training, your abilities, your ethics. It was never the same again. Every procedure was attended by a third party: the legal system. It was heavy, that extra weight.

Your patient needs you again. The head is at plus 3, and there are some decelerations of the fetal heart rate. You calm her, then yourself. You see the hearts recover and heave a sigh of relief.

You don't want this last delivery to have a single problem, for her or for you. You hate having to consider liability issues at a time like this, but you know that it's part of your world. Your insurance premiums have jumped 250 percent in the past two years. When the most recent estimate came in the mail, you knew that you could not continue your practice as before. A decision had to be made. You pray that it was the right one.

She's close now. The head is crowning and the hearts are down. Push, push. Your baby needs you. The vertex delivers suddenly and you are flooded with relief and joy and pride and humility. The newborn boy is shown to his mother and crying father before being handed to the waiting nurse. As you deliver the placenta and repair the small laceration, you wonder what you will do.

You have informed your insurance carrier that you will not be paying your next premium. You cannot. The hospital will take over your practice, but you will not be there. Your patients have been informed and your office packed.

You do not yet know what you will do, where you will practice, even if you will practice. You've considered teaching or taking a job with a pharmaceutical company, but as you look at the beaming mother and her perfect newborn, you know in your heart that you are not ready to abandon medicine.

The family has been congratulated, paperwork completed, the goodbyes said to the staff. You look around and realize that this is no longer your place. Your battle awaits you. It is time to go.



The author is an ob/gyn specialist in Philadelphia.


Carolyn Chambers. Last Word: The last delivery. Medical Economics Aug. 22, 2003;80:88.

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