Blog | Wednesday, October 3, 2012

When medical protocols become a straightjacket


Recently I learned about a pregnancy in which the woman was having frequent painful contractions. Only after her eventual delivery was it clear that she had developed a "uterine window," where the scar from a previous C-section was almost worn through. The woman was told, after her Caesarian, there had been a significant risk of uterine rupture.

But why then was she not delivered earlier? Because, answered the doctor, there are risks to the baby from preterm delivery.

In that case, what was the balance between the risk of uterine rupture on the one hand and the risk of preterm delivery on the other? No one seemed to consider this tradeoff, or at any rate discuss it with this woman. She kept reporting her contractions; she was reassured and pain relief was provided; but preterm delivery was never considered, as if 39 weeks were carved somewhere in marble.

Such hidebound protocolism is the norm across medicine. The blood pressure must be lower than 140 over 90, because... well, because guidelines! The hemoglobin A1C must be lower than 7 because the American Diabetes Association said so, because ... they are the experts!

Of course, those who recommend these cutoffs are experts. But that does not mean there are never any countervailing concerns or other possible routes. Is there a way to flip the protocol switch to "flexible" in doctors' heads?

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews. He is also a poet, journalist and translator in Yiddish and English. This post originally appeared at his blog.