Planned home birth and the Business of Being Born

I heard about Ricki Lake's documentary, "The Business of Being Born" while I was an OBGYN resident at Emory University. Recently, a colleague watched it and I figured it was worth a go especially since my wife and I just had a baby girl. Having performed hundreds of deliveries (some with midwives) and now having a new perspective as a father, I thought it was time to see what the hubbub was about. Hit the break for more!

GETTING TO 30%: THE 6 YEAR MEDICAL SCHOOL MODEL

This post debuted on 5/13/2012 on KEVINMD.com: 

As a teenager in the mid-late 1990s, my father, an engineering educator, and I would talk about the ills of the healthcare system and how physicians lost control of healthcare: primarily because they concentrated on medicine rather than the forces changing healthcare delivery. I realized this was due to an outdated medical education system and reforming it might actually improve healthcare in this country! That was my Sputnik Moment!

Since graduating high school in 2000, I have been involved in medical education without interruption. I completed my BA/MD from the University of Missouri Kansas City’s (UMKC) 6-year program in 2006, and then moved on to be an administrative chief resident in the OBGYN Department at Emory University. I currently serve as a Fellow in the Division of Reproductive Endocrinology and Infertility at Washington University-St. Louis School of Medicine.

My Sputnik moment was re-ignited after reading the recent article by Ezekiel Emanuel, MD PhD, and Victor Fuchs, PhD, which highlights the 100-year-old dilemma that is medical education in this country. Their commentary describes the pathway to becoming a subspecialty physician in this country, and proposes reducing the length of medical training by 30 percent in an effort to reduce health care costs.

While it’s easy to become polarized by the political elements of Dr. Emanuel’s proposals, we are ultimately distracted from the main point:  medical school is expensive and a more efficient, cost effective
,
path toward a medical degree should be available.

UMKC’s School of Medicine’s model of medical education has thrived for over 40 years, graduating more than 3,000 physicians since it’s beginning in 1971. The pathway for medical education reform should involve guiding students from high school into medical school, where they can be placed into learning teams, and avoid the MCAT and its predatory preparatory course costs. Over 60% of graduating medical students report taking a prep course, which can cost upwards of $9,000. A year round, 6-year approach is more efficient and does not sacrifice quality or leadership in building the next generation of physicians.

With an average medical student debt burden of $157,944, by shortening my medical training a full two years, I effectively reduced the cost of my medical education by 25% (my tuition varied over the six years; approximately $18-22,000 over 6 years from 2000-2006). And let’s not forget that the $157,944 figure represents the loan burden after four years of medical school. Furthermore, the AAMC’s figure does not account for the additional $12,400 average tuition related debt per undergraduate degree accumulated prior to entrance into medical school.

In 2011, 47.3% of graduating medical students reported their decision to become a physician came before or during high school, while 24.2% decided to become a physician in the first two years of college Youth are more informed and able to access information, utilize technology and exchange ideas much easier than when Abraham Flexner’s report on medical education came out in 1910. The complexity of medical knowledge has changed immensely, but our education system has been slow to catch up. One-hundred years later, it is time to revisit Flexner’s report

A 30% reduction in training length is attainable by providing an option for pursuit of a combined BA/MD degree in the vein of my alma mater. Such a track will lower costs and shorten the time to workforce entry, while adding time for research fellowships and/or humanitarian opportunities. Additionally, as women comprise half of all medical school graduates, as a reproductive endocrinologist, I must point out that a condensed approach has positive ramifications on future fertility in the era of delayed childbearing and increasing infertility.

 Ultimately, such a 6-year track may not be for everyone, but for the high school graduate who wants to have a career in medicine, be it as a clinician, physician/scientist or public health guru, an option for an accelerated path to achieving an MD degree provides a highly employable skill set with a lower debt burden that will only benefit the delivery of healthcare in the 21^st century.

Kenan Omurtag, MD is a board certified OBGYN and Fellow in Reproductive Endocrinology and Infertility at Washington University-St Louis School of Medicine and is a 2006 graduate of the University Missouri Kansas City School of Medicine.  You can follow him @stlinfertility

Birth Defects and IVF

Attachment Parenting, Same sex-marriage, birth defects and IVF? A busy week for Women's Health

WOW! what a busy week last week was on many fronts that probably captured the attention of many in women's health: new TIME magazine cover, NEJM article about birth defects and IVF, and president Obama's announcement regarding his position on same-sex marriage.

I will focus my attention by commenting on the NEJM article. Using birth registry data from Southern Australia, the authors compared an infertile population to a normal fertile population and show that there is a 8.3% birth defect rate among those women treated for infertility (5.8% in the "normally" conceiving population." In any cohort study confounders must be controlled for and here the authors do this but some have argued that when differences between the populations (one infertile and one fertile) are too great djusting for confounders is not enough.

The one, perhaps simple finding that I gravitate towards is the % of birth defects among those undergoing IVF (105/1484=7.1%), IVF+ICSI (91/939=9.7%), and history of infertility with no history of any ART (52/600=8.7%) VS those who had a spontaneous conception (5.8%) - reinforces to that it is the underlying infertility, and perhaps the older population of the infertility cohort and not the treatments that may be responsible.

Eitherway, the article's findings suggest that there are subtle associations between infertility treatments and birth defects. Remember, that in these cohort studies, association does not confirm causation. While their findings should not be ignored, their work highlights a topic that is already discussed in infertility clinics worldwide.Their findings reinforce the conventional wisdom that it is the underlying infertility and not the treatments that are leading to the increase in birth defects.

But don't take my word for it here is the official response from the American Society of Reproductive Medicine (ASRM) and the Society for Assisted Reproductive Technology (SART):

A paper published today in the New England Journal of Medicine noted an increased incidence of birth defects in ART-conceived children.  ASRM and SART responded.

Statement Attributable to Linda Giudice MD, PhD, President-elect of the American Society for Reproductive Medicine (ASRM):

“This study confirms what has been known for quite some time: Patients who need medical assistance to conceive have a somewhat higher risk of having children with birth defects than parents able to conceive on their own.  Patients considering medically assisted conception have been, and should continue to be, counseled on those risks prior to undergoing any treatment.”

Statement attributable to Glenn Schattman, MD, President of the Society for Assisted Reproductive Technology (SART):

“It is important to note that women with a history of infertility who did not undergo ART treatments also had a higher increase of having children with birth defects. This combined with the finding that those using ICSI (Intra Cytoplasmic Sperm Injection) also had slightly elevated risks of birth defects suggest that  the underlying problem that led them to seek medical assistance in the first place is likely contributing to the elevated risk of birth defects in their children.

Some results in this study are reassuring for patients: in cycles not including ICSI, the adjusted odds ratio for IVF conceived children did NOT show a significant difference in birth defects children born following embryo freezing had no higher risk of birth defects than naturally conceived children.

These are interesting and important findings and we will need much more research to allow us to help patients overcome their infertility with treatments that are as safe as possible for them and the children born from the treatments.”

Please comment, but keep it civil.