Thinking About Ob/Gyn
A fresh and evidence-based perspective of all things related to obstetrics and gynecology. Follow us on Instagram @thinkingaboutobgyn or visit thinkingaboutobgyn.com for show notes and more.
Thinking About Ob/Gyn
Episode 10.11 Smarter Cancer Screening, Safer Obstetrics
We share a practical, clinic‑tested system for hereditary cancer screening that standardizes intake and education, then confront how malpractice pressures distort obstetric decision‑making, fetal monitoring, and access to care. Former ACOG president Dr. Richard Waldman offers data, history, and solutions we can use now.
• digital workflow that screens every patient annually from age 18
• video education improving informed consent and test completion
• one in four patients meeting hereditary testing criteria
• management changes after testing including MRI, meds, referrals
• addressing cost and genetic discrimination concerns
• OBGYNs as leaders in genetics amid counselor shortages
• malpractice landscape, rising verdicts, and physician burnout
• neonatal encephalopathy criteria grounding courtroom science
• fetal monitoring limits, category II overreaction, cesarean pressure
• VBAC safety tied to selection, readiness, and team systems
• safety culture, simulation, and checklists reducing risk
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Follow us on Instagram @thinkingaboutobgyn.
Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Richard Waldman discussing cancer screening and medical malpractice.
SPEAKER_00:Howard?
SPEAKER_03:Antonia.
SPEAKER_00:What are we thinking about on today's episode?
SPEAKER_03:Well, we're going to listen to an interview that I did a couple of weeks ago with the past president of ACOG, Richard Waldman. He and I discuss an article he had earlier this year in the Green Journal about improving screening for genetic familial cancer syndromes in our clinics. And this is something he's worked on for several years. We'll also discuss another article that he published in the same vein a few years ago and the personal sort of reason why he pursued this in his career. I do think that cancer screening like this is important, and it's one of the things that we do in our clinics and from a primary preventative care perspective that can have the biggest impact on the longevity and the quality of life of our patients.
SPEAKER_00:But yeah, there there's so many other things that we do on a daily basis that are marginal benefit at best. But when you find a patient who has a genetic cancer syndrome and then you do the appropriate screenings or even risk-reducing interventions, you really do dramatically change the trajectory of their lives and the lives of their families.
unknown:Yeah.
SPEAKER_03:Well, Dr. Waldman's also worked a lot in his career on the medical malpractice crisis that historically and continues to face OBGYNs. And so I had a chance to discuss that with him as well and the continuing problems that we have with sometimes absurd lawsuits, frivolous lawsuits, which threaten our profession and frankly are a leading cause of moral injury and burnout among OBGYN physicians who are certainly tempted to leave obstetrics or at least leave the delivering babies part of our careers, especially in if they get an opportunity to later in life or to transition to GYN only or something like that because of this.
SPEAKER_00:And in the time since the time that you did that interview, there was also a New York Times article about that specifically. It was about fetal heart rate monitoring. So maybe we can discuss that after we listen to the episode.
SPEAKER_03:Yeah. Well sounds good. So let's listen to my conversation with Dr. Waldman, and then maybe we can discuss that New York Times piece. Okay. And we're really lucky today to have Dr. Waldman with us. Dr. Waldman, you're a past president of ACOG. That was in 2011 or I can't remember exactly.
SPEAKER_02:2009. Oh, 2009.
SPEAKER_03:Yeah. Well, it's kind of a three-year term anyway, so you've been busy before and after that with ACOG, but a past president of ACOG. So welcome to our podcast. And on this podcast, we talk a lot about papers and recent publications. And here we've just gone straight to the source. So you had a paper in 2025 in the Green Journal called Online Screening and Virtual Patient Education for Hereditary Cancer Risk Assessment and Testing. And it tackles the major challenge, which is identifying and educating patients about hereditary cancer risks. So could you maybe start us out with describing the problems that you see every day in your practice that made this new online or virtual approach a necessity for our patients?
SPEAKER_02:Aaron Ross Powell Howard, this all started way, way back when. That was before any genes were identified. And then she got breast cancer at the age of 42. And that was breast cancer before BRCA1 and BRCA2. And you know that BRCA I and BRCA2 were pioneered by Marriott in 1994. So we always expected because of her personal history and her sister died from breast cancer that along the lines that she would turn positive for one of the genes, which it happens that she didn't. And so we had an interest, personal interest, and a clinical interest in genetic connections to disease, especially cancer. And what we found was that it was very difficult to find genetic counselors. The only genetic counselor in Syracuse at that time was in the pediatric department and it only saw patients a half a day a week. So we ended up having to learn a lot because we had to counsel our patients a lot. And then we started working with Myriad and developed systems to screen patients in our office. And we had to develop a system so that every patient was screened. And so we've created a form that every patient would fill out in the office. We had to get the form actually had to be according to NCCCN guidelines, and we had to make it so that everybody in the office could understand it very easily. But it had it, you all the positives had to be on one side, no matter how the question was asked, so that you could look at it for 30 seconds and understand the patient's risk for genetic cancer. And we recognized that it's not that easy to do in large practice. At that time, when we did this study, we had 17 providers, physicians and nurse practitioners and midwives, and everybody was different in their ability to both screen patients, identify the patients at risk, and to educate the patient. Everybody was a little different in their ability. Somebody like me who had been doing for years was very facile at it. I was at the highest level. But then you have new residents who are trained who have very little education in genetics and genetics relationship cancer. So we were looking for a way to screen every patient the same way and educate the every patient the same way. And so we developed this digital program with Myriad. They were a really great partner. And we've been working hand in hand with them for a long time. And so we developed this digital system where every patient in the office is screened, and it's screened by the same screening technique. And then every patient is educated by the same educational technique. And it worked out really well.
SPEAKER_03:Yeah, and I think you've done a good job there. None of us are perfect, even I'm sure you said you were at the top end, you know, obviously a personal story for you, but none of us are perfect. We miss things or the histories are incomplete. And so you've tackled that with this issue. This we recommend this screening, but we do have a lack of time, tools, expertise, or confidence, I think, as you say. So how specifically does this digital workflow that Miriam you've designed, does it solve those four problems for the provider?
SPEAKER_02:Yeah. The number one problem is time. I think how difficult it is to operate in today's world from an OBGYN perspective. So we needed to come up with a system that was very efficient, and this certainly solved that problem. The education, we solved the education for the patients with the digital program, and we also educated the OBGYN staff at the same time. The obstacles, education, and burdensome time were solved by this program.
SPEAKER_03:And in your paper, you found, I guess, the guideline eligible patients. The number of patients increased from 21.6 to 28.2 percent was your one of your key findings. So what kinds of patients was this that you described this system a lot of us have done, the cumbersome paperwork out front or the history that we take? So what kind of patients were we missing with this non-digital approach that a lot of us have been doing?
SPEAKER_02:I think it's really important to point out that I believe that every patient should be screened every year in this manner. Their family history changes. And you start at age 18. So the now for Lynch syndrome, for instance, they're starting colonoscopies on Lynch syndrome patients at the age of 20. And you know that these cancers occur earlier. They are the way you identify them is cancers in the family that occur earlier or more or frequently. There's more than one cancer in the family at the same person, or rare, like a male breast cancer. And those are some of the signs. So when we increased the numbers from 21 to 28, it was really, if you look at it, those people in the study had all been doing this screening before. So what really changed was this system where it was you couldn't miss it because everybody was screened, the staff was screening everybody, and everybody, every patient was educated. So it's it wasn't a one group of patients that was missed. It was really the an entirety.
SPEAKER_03:And beyond that, maybe the more dramatic result is that there was a roughly doubling, a little bit better than doubling, of the rate of genetic test completion from 16 to 34.2 percent. So that's a result of the two parts you're getting at there, the online tool, but then the education, because it's one thing to for me to screen you and identify your risk. It's another thing for you to buy in as the patient that the testing's important. So in your view, which of those two parts was they're both important, but the education clearly is also a very effective part of this because people need to understand what it means that they screen positive and why the testing might be helpful.
SPEAKER_02:And I think they're both equally as important. The you can you can't educate patients if you don't identify who's at risk. So that's the number one. But the uh it is critically important to have an educated patient. And even if the patient decides not to do the testing, which is certainly their right, we certainly agree with, you want it to be an educated no. You want them to say no for the right reasons. So, equal equal want you can't do you can't do it without screening, and you can do it without education, but this was improved the education for the patients tremendously, and that's why we saw the increase in the numbers of people being tested.
SPEAKER_03:And you had good buy-in. 92% of clinicians agreed that the tool was helpful in improving identification, and 90% of the patients felt that the virtual education helped them understand the purpose and the implications of the testing. So were you surprised by that level of buy-in, especially from busy clinicians who might be skeptical of another screen or another tool, another thing they're being asked to do?
SPEAKER_02:Actually, I wasn't surprised at all. I found that the docs weren't suspicious of the testing. After they understood what was happening, they really enjoyed being taken off the hook, so to speak. So they didn't have the responsibility of having to do the patient education. So I was not surprised that they found this to be a very uh easy and facile program. And they I, as you can see from the numbers, they didn't, they were very pleased to participate.
SPEAKER_03:And you had two, there's two educational models, and you can explain that to us a little bit. There's the video education and then the video telephone education. So both led to ultimately led to similar testing completion rates, and but the education completion rate was higher for the video only group at 90% versus the group that also required, I guess, a phone call, 35%. So, what does that tell us about patient preferences, I guess, for how this education should go and how they deal with complex information?
SPEAKER_02:Well, uh this one might be a little hard to figure out, but I think that the patients enjoyed the video better and the video did a more consistent job of education. And when the telephone calls were done, they were telephone calls with myriad genetic counselors, very quality individuals, board certified in genetics, but they weren't always the same. The other thing is that the there's a time factor too, I think. Sometimes the telephone calls were rushed by the patient, sometimes the telephone calls were hard to reach, and then they was causing a backlog in the office, and they weren't given enough time. So the the telephone conversation was a little bit more awkward than the video. The video was more consistent, and and uh you could see it worked a little better.
SPEAKER_03:Yeah. And this isn't your first obviously, you told us your personal story about that. You've been at this for a while. In 2018, you had a sort of predecessor study, hereditary cancer genetic testing in community-based obstetrics and gynecology settings. And so that seems to me to be the predecessor of what this has led to. And that study also showed a substantial improvement in genetic testing by implementing just a process, essentially. So, how did that process work and what'd you learn from that that led to this one?
SPEAKER_02:Well, both studies are very similar. There's a lot of things that we did in the first study that we did in the second study, and that really helped us get the second study started. The pre-test the pre-education, the pre-study, the pre-ed the education, the post-study practice period, and the and the then the test period were all pretty much the same. It's the most important thing, which I haven't really pointed out, was that both studies really showed one out of four people who come into a gynecologist's office qualify for genetic testing. And what's not in those tests is that one out of 18 of those people who are tested test positive, and 50% of the people who are tested change the medical management that they do in their life, either by increasing surveillance, or we saw a lot of patients with, even though they didn't have a what I used to call a big gene problem, they had a higher risk of being breast cancer, over 20%. So we were sending a lot of people for MRIs and into the surgeons for evaluation. And you can it's important for everybody to know that just having a gene isn't a death sentence. You can do things, you can give people medication, you can do surgery, you can increase surveillance. And the other thing I just want to mention is the fact that this is not one person that you're dealing with. When you do a history like this, you're really helping an entire family. And we have so many instances where this testing, either by negative or positive, then went on to help the entire family understand the issues that were going on. So I'm not sure I got to your question.
SPEAKER_03:No, I am and this is the future of medicine. When people talk about personalized medicine, we're going to be integrating genetic information more and more into not just risk assessments and who needs what screenings and when, but also selection of therapies for both cancer and non-cancer things. So the future generations will need to be very comfortable with this sort of process that I think in 10 years people will just have genomes and will access this information through systems. And but with that is going to come a lot of burden of understanding what these genes mean and how when we want to know about them and how we what we do about them. So this sort of stuff is the future for sure in terms of how we make a difference. And if you find a young woman or who's 30 that has a BRCA gene mutation or a Lynch syndrome mutation, that's in the scope of things we do every day for patients that age, that's probably the most important thing we could do in terms of life expectancy and quality of life and affecting population-level health. So and both papers conclude that OBGONs are capable of counseling and ordering hereditary cancer genetic testing, and but we need tools to make it feasible. So how has the role or perhaps the comfort level, do you think, of community OBGYNs in managing genetic risk evolved between these two studies, or has it? We need counselors, we need access to counselors to do all this, I guess, is part of that. Some people do a great job, but it's not consistent, maybe.
SPEAKER_02:I think the real hope for women is the OBGYN. Our experience with other specialties has not been fantastic. The internal medicine docs have not been all that interested in this. The family practice docs have not been all that interested in this. Some of the oncologists are still not testing patients with genetic tests like BRACA, et cetera. So I think the OBGYN is our hope for getting this done more universally throughout the country. And they we we've proved that they're capable, but it's also the standard of care. And that's an important facet. So more OBGYNs need to do that. I think the way we see our patients on a yearly basis puts us in a better position to be care caring for the woman and the entire woman at the at every visit. Each yearly visit is an opportunity to evaluate them for their genetic cancer risk.
SPEAKER_03:And this isn't just theoretic, right? This online screening program is available for people to use.
SPEAKER_02:Oh yeah. They can get to Myriad and get to their website and they can get any information they want from the Miriad.
SPEAKER_03:Okay. Well, I want to shift to something because I since I've got you on here, I've known your name for a long time for a different area, a different paper, and it's a paper that I guess you published right around the time you were becoming ACOG president in 2009, called A Proposed Model for Managing Cases of Neurologically Impaired Infants. And and so you've worked on this issue, I think, through a lot of your career too, which and you're a couple of years older than me. So there was there were some really bad days of the medical malpractice crisis, and then it's generally seemed to have been better for OBs in the last few years, and maybe that's rebounding. There's some evidence that it's getting worse again since COVID. But in your 2009 paper, you called the tort system for neurologically impaired infants extraordinarily inefficient and expensive and unfair to families and physicians. And I certainly hear colleagues talk about the concern with some of the larger settlements that we're seeing in some of these cases, wiping out all their personal savings or like they're it's well above the limits in some of these cases. And the insurance carriers and the doctors and the hospitals are carrying the burden of worrying about one huge settlement case that shuts down the business or makes it too inexpensive to maintain a rural access hospital. So 15 years or so after that paper, has this changed? Is are we still stuck in the same flawed system? Have we solved the problem? I think I know the answer, but I want to hear your thoughts.
SPEAKER_02:Back in that day, we had an early experience and we saw how terrible the court system was in in New York. And everything I did along the lines when I was district chair in New York was about tort reform. And actually, we had a governor who came in for a short period of time who was anxious to get tort reform. New York is bad for so many different reasons. We have some of the highest losses. Over$100 million losses are not that unusual. You can have what we call, we used to call experts come in by ambush because you didn't know who was coming in to testify. And that really put a damper on it. And the other problem that we had, and I think other states had the same problem, we had to stop doing quality reviews in our hospitals because they said that any quality review done on the institution was admissible in court. And so instead of having this problems being improved, it actually made it worse. And I actually had joint meetings with the Bar Association in New York, and we could not move them even an inch. We could, however, we couldn't move them to change the quality, being able to access quality, and we couldn't move them to being able to to being able to attach personal assets because they're just tools that they used to threaten people. So what we did in in New York is we turned to safety and we looked at the issues that were the highest rates in New York, which was breast, which was fetal heart neonatal encephalopathy, and shoulder dystocia. And I think that's where a lot of the stuff that came out across the country about safety and quality came out of New York, actually, because we recognized, for instance, that the when they changed the definitions of terms in the in fetal heart, we gave courses across the state to every area where physicians could come in and get the the get courses on how to interpret fetal modern and then shoulder distos. A lot of the things that you see in your records today detail how to put into records the appropriate notes and how to do it appropriate. And we did simulation. We brought all that to New York. And that was one of my approaches was it was the safety for the patient, but it was also safety for the physicians in a way. Prevent them from being vulnerable.
SPEAKER_03:Well, one of the points you make in that paper, which we've done an episode of the podcast, I guess a couple of years ago, looking at some of this data as it's evolved, but you made this point that we made recently in that paper that while the C-section rate rose from 5% roughly in 1970 or so, to over 30% in when you wrote the paper, and certainly it's around 34% now, mostly in an attempt to prevent hypoxia and in theory help reduce the incidence of cerebral palsy. Well, during all that, since 1970 to today, it termed babies and the babies that we're worried about here, the incidence of cerebral palsy has remained, as you said, rock stable. So again, we talked about this recently. A lot of the thought leaders, the Stephen Clarks, the people who are really interested in this issue have pointed out that our interpretational fetal monitoring, our management fetal monitoring has seemed to make no difference at all in the incidence of at least term cerebral palsy. So is this fact as poorly understood by the public and the legal system today as it was then? Have the bad baby cases gotten better because of that work on defining hypoxyxemic encephalopathy and which cases are really relinked to cerebral palsy and which aren't?
SPEAKER_02:Let's go back to that paper for a second. Our concept was every baby with cerebral palsy needed financial support.
SPEAKER_03:Regardless of the cause.
SPEAKER_02:And if that occurred, we would we would be in a better world today. The I don't believe that we have changed the rate of cerebral palsy at all today and compared to everything that we're doing. And I think there's several reasons for it. But one of the reasons I don't think everybody really talks about is a lot of the damage that's done to these babies is done before they ever get into labor. And labor didn't cause it, and labor was just reflecting what was going on already. Babies can have strokes, and babies can have synthesis that are not working. And that can present in labor and determinately, and everything we do is not going to change the outcome. And that's really basically what we're saying. A lot of the cerebral palsy has nothing to do with labor management. And we certainly, by the Clark study, that he couldn't come up with a way of preventing for a better outcome using the new fetal heart monitoring system.
SPEAKER_03:Yeah, and it's interesting too that even in if you look at the rates in non-labored, like scheduled planned cesareans, it's still there. And that already damaged baby may have late decelerations on the unit when they present in labor, and we may act on that, but the damage was done prior to that in so many cases. You hear the number 94% or something like that, roughly, of cerebral palsy cases have something that's clearly not related to intrapartum events. And I guess that's also the emphasis on looking for the big key thing. You had a normal tracing and then you had an abruption, or a sentinel event that led to that, a cord prolapse or something that directly you can see a difference before and after. So in that paper, you talked about this, and people still talk about this, Dr. Wallman. Don't worry, because people my age are desperate to, as I said, protect their hospital units that are paying absurd malpractice premiums and our colleagues who are sometimes facing these monstrous settlements. But you proposed a neurologically impaired program for your state and a no-fault model that would provide financial support to, as you said, all families, because for everybody, whether it was a pre a prenatal issue or some other issue or an infection or whatever, this is devastating for a diagnosis for the families that have to raise these children. So it would be a financial support program for a neurologically impaired child, regardless of why that happened. And a key part was separating financial support from the standard of care evaluation so that negligence could still be addressed, but families didn't have to w win this jackpot, this legal lottery, essentially, to get help. So what happened to that idea? And has any state done anything?
SPEAKER_02:Florida has a pretty good program and it was working for a number of years. I haven't looked at it recently, so I don't know whether it's still functioning. But we s looked at the program in Florida and we used some of the things that they were doing there to base our study. Of course, it never went anyplace. The legislature had no interest in pushing this program forward. And so we're we thought it was a great idea. We still think it's a great idea, we would still back it, but that's not the way the politics works in New York, and I'm afraid it doesn't work that way in a lot of states across the country.
SPEAKER_03:Yeah, and that's what you said. You said you don't expect it to be accepted and the issue's too political, so so uh sage pronouncement. But what does that tell us about the challenge of meaningful tort reform? Apart from these sort of bad baby programs, if you will, so many states, like Florida, you mentioned, I think the majority of OBs in Florida are practicing without malpractice insurance right now. They're practicing bear. So it doesn't seem like we've done some states have had reasonable success with tort reform, but on the whole, it's not something that's popular.
SPEAKER_02:I think they they practice bear because they can. They they can't attach, they put everything into their personal assets, and the personal assets can't be attacked by bankruptcy. And so they have wor learned to live you're exactly right. It didn't change a lot from that perspective. But they don't get insurance because the they found a way to put everything in their personal assets, and personal assets can't be attached. Trevor Burrus, Jr.
SPEAKER_03:In the state of Florida. But if you're in another state, you may not have that advantage. Trevor Burrus, Jr. That's correct.
SPEAKER_02:But I I don't know, Howard, have you heard of any other state that with liability reform? I haven't heard anything recently. Trevor Burrus, Jr.
SPEAKER_03:Well, some people have caps. Georgia just got some caps. My state, Tennessee, has had caps for a few years. There's been a few little things there. But the thing about a neurologically non-intact baby like that, that when you look at the projected lifetime costs, is of course those non-punitive, real economic damages are always there. And that's where you see some of these huge settlements that come about that just make it very uninviting to run a small labor and delivery unit in a rural area that might only do 300 deliveries a year, and your whole system is bankrupt by one bad settlement, or you can't afford the malpractice insurance.
SPEAKER_02:There's a lot of bad situations that occurred. I when I was traveling around New York City and giving talks, the doctors there would tell me they couldn't afford to go into practice because they couldn't afford the liability insurance. And what do you need in those cities? You need plenty of private practitioners delivering quality care. So that's just one example. Physicians are very damaged about can be very damaged. And it's really it's really a challenge sometimes to get back into the saddle and be able to practice again. When I was president of ACOG, we did a program called Second Victims that we did a videotape on it. And part of the second victims are victims who are victims of liability cases. The first thing that happens when you have a liability case, first thing they tell you is don't talk to anybody. Don't you only talk to your lawyer. I can remember going around the country meeting people who were so devastated by the fact that they had a case and then they're devastated. One one mother daughter combination, the daughter was told not to talk to her mother. They were both OBGYNs, and she didn't have anybody to talk to. So it really causes. And I've seen people I've seen in in in Syracuse, we saw two people, at least two people, drop out of practice immediately after a case. One was a one was a shoulder dystocia case that she didn't have really anything to do with. Another was an OBGYN who gave up OB on the spot after that case. That's not good. He didn't do anything wrong, by the way, just as an aside. He was an excellent physician who did excellent work. And that's the damage of taking bad cases to court.
SPEAKER_03:Yeah, just because you're maybe looking for the lottery or answers. This isn't any this isn't the patient's fault either. They're looking for answers and they want to understand what's happened.
SPEAKER_02:That's a that's what I find in some of the cases that we look at is the patients are given the concept that the doctor did something wrong. That's another piece of this because then the patient never has the opportunity to grieve properly. Instead of grieving for the loss of a baby or grieving for a problem with the baby, they're grieving and they're angry that somebody caused it, and nobody really. Talks much about that. I had that happen to me actually. We had a case where we had a non-immune hijops baby. We saved the baby's life. It was the best resuscitation I'd ever seen. They did you may not have ever seen this in your career, but they the pediatric team did bilateral lung taps, abdominal synthesis, and intubation all at the same time and saved the baby's life. And she was told that we didn't deliver the baby early enough. So instead of being thrilled that the baby survived a really difficult, not immune hodgeous condition, she went for years thinking that and then when the lawyer figured that he couldn't win the case, he dropped the case because the care was exceptional. Those are Yeah.
SPEAKER_03:No, or the shoulder dystocia that saves a baby's life, but then you're left with a palsy and it's the same sort of approach.
SPEAKER_02:In my presidency, the one of the main things that I did, Mary Dalton, who's the chair at Columbia, came to me and she said, Richard, we have to redo the neonatal encephalopathy treatise. And I asked her a couple questions and she said, Well, it's not being useful, people are questioning the results. So we reformed the committees, and that was that still today, Howard, is being looked at. That's probably the major reason we are able to defend HIE cases in court today, because that document is still solid, and it was really well done. And by approved by both the Pediatric group and the MFM group and the ACOD group. And so it had broad support. And that in some ways probably the best thing that I did. Yeah, I'm sorry.
SPEAKER_03:I was gonna say people say it's the most peer-reviewed document that's ever been put out because so many organizations signed on to it. Unbelievable.
SPEAKER_02:It was a great committee. I can't think it wasn't my clinical expertise that did it. We brought in experts across the country who were superb. The other thing that I did was I re-invigorated the Maternal Mortality Committee. So the Maternal Mortality Committee was sort of going and fading, and I was able to re-establish it and re-invigorate it. And we had experts from across the world coming in giving us lectures on specifically on how to decrease maternal mortality. The other thing I did was it really encouraged the better relationship between the American College of Nurse Midwives and the ACOG. We put out a joint statement at that time, and I was actually we did a study and we were able to publish 14 papers on collaborative practice, which was also had never been done before. Collaborative practice between obstetricians and objuans and midwives. And I think what that does is better collaboration is a step towards better better protection and avoiding lawsuits. So I I did I also had a lot to do with changing the ACOG attitude towards safety and checklists, uh, which we started looking at checklists at that time when I was president. So those are all good and they they impact on liability, all of them. In one way or another.
SPEAKER_03:Yeah. Okay. Well, the other thing I remember around that time, and I this is a while ago, and I but that we uh that I wanted to ask you about it, was it was around that time that we went to you could V back after two prior cesareans without a prior vaginal. And that's certainly been a big part of my career because I've done so many of these since the guideline changed around that time. And I don't know what your philosophy is about cesareans. I'm just guessing that you think that we probably do too many of them. And yet we do that, we're in this context of of fear of lawsuits, fear of a lawsuit from any uterine rupture, fear of lawsuits from all sorts of things, and that has to contribute to the cesarean rate. But we're still at a point where I don't know the exact number, but my guess is most practicing OBs really don't offer feedback even to people who are great candidates with prior vaginal deliveries in one cesarean for uh breach presentation or something. What is it gonna take for people to feel psychologically safe to do things like VBAC in uptake that more, apart from what we've already talked about, I guess, or including that legal tort liability reform, or why do people not feel safe doing things like VBAC? Our colleagues.
SPEAKER_02:I was the uh first physician in Syracuse to do VBACs. I did the first VBACs patient who was a very cesarean, anti-Caesarean advocate came to me. She showed me some of the literature. I looked at our own literature and I said, She's exactly right, this is something we need to try. And we were doing VBACs, and I was doing VBACs for years, and our success rate was very high, and I never lost a baby. And you bring up a couple of factors though. I believe after the studies that came out with the uterine rupture, that we need to be able to monitor these patients continuously. We need a system where you can do a C-section in what we call code C, do a quick cesarean section. You need to select your patients well. And you you need obviously to avoid some medications for induction, and you also need to respond to like what one of the things that I would see is a patient would get in continuous pain and the epidura would not be working, or you would they would get pain in the lower abdomen that was different in the cesarean section site, and you needed to respond to that. Two things happened. One was that after we started doing VVACs, all of a sudden the insurance company were insisting that everybody do VVACs. I don't know whether you know that or not, or so at least the insurance company said, Well, this is a great idea. Everybody should have a VBAC. And that was not the way to do it for sure. And then we had the same problem in our practice. We had we had some people who would do VBACs and other people who won't. And the people who do VVACs weren't willing to come in on their night off to do the VBACs and attend to the patients. So we had to give it up. And that was painful for me. I couldn't see a way around it, but it really points out the problem of VBACs today. So still, good selection. I don't see any problem with doing VBACs at all. But don't do a three-day induction with a closed right? And say to the patients, one plus one in VBACs equals three. If you have one complication and then you get polyhydromnius or twins, just take this repeat C section. So we and I'll tell you, what we looked at was the total repeat cesarean section rate and our success rate. That's the only set that's the only number you can look at. You can't look at the number of successful VBACs that you have if you are highly selective. You have to look at what's your repeat cesarean section rate and your VBAC rate, uh the total group. And I we were, I can't remember exact numbers, but we were very high. I was a very strong advocate for VBAC, never had a problem. And I feel the pain of the people that can't have it. Now, I've also seen situations where people can't get VBACs and they reach out to people who shouldn't be doing them.
SPEAKER_03:Or even home birth VBACs.
SPEAKER_02:Exactly, which I totally am against. Yeah, and for midwife's doing VBACs without physician on board. You you need to do the VBAC, but you need to be ready to have a C-section and you need to have a physician to do a C-section there.
SPEAKER_03:Well, I'm going to give you the last word and let's go back to what we started with. The other thing I point out about your paper was again, what about a third, 34% of the eligible patients completed testing, which is better than the 16% that you had in in to begin with. But what's next? What's the next barrier? Do you have more thoughts about this? How do we get the 34% number increased?
SPEAKER_02:I think the number one issue is it may never be any higher than that because the patients are making a decision on genetic testing, and that needs to be totally respected. If you look at any of the literature on neurological diseases like Huntington's or other problems, there are always families in that some of the families get tested, and some of the individuals in the families don't get tested. Some people are afraid to have the test. So what I said to you before is we need informed no's. We need to know, for instance, that there are things that you can do if you have a positive test. There's things that you can do for your family if you have a positive test. Having a negative test can be useful for your family sometimes to know that it's negative. There is no downside insurance-wise to getting genetic testing. And that's a big question that comes up very frequently. The they're afraid that they'll not be able to get life insurance. Right. Or they're not be able to get health insurance. But it's against the law federally. I don't know how we got this passed, but early on they passed a law that says that you cannot be discriminated against if you get genetic testing. And I think that is people need to know that because sometimes they make the decision because they don't want to know, sometimes they make the decision because of cost, sometimes they make the decision for the wrong reasons. By the way, on the myriad piece, they've now when we started doing a study, and if you look at the study, both studies, some people got tests sent, but some got rejected because of cost. And early on, when we were trying to do a lot of the work, the first question of people were will insurance cover this? And if insurance doesn't cover, what is it going to cost us? And that was not being handled in a way that was satisfactory to the patients. They were not willing to risk that number. But to now I understand that Mary has a number that they give them that's under$300 that's set. And so if the insurance is not covering it and they can do it and pay, pay in in I don't know the details, but they can they can pay it off even in$14 a month or something. So cost is also important. A potential barrier. We didn't talk about it. But the other piece is that if they come one year and they're offered the testing, it doesn't mean that when they come back the next year, they're not going to go for the testing. And so I think that's a good question.
SPEAKER_03:Yeah, cumulatively you may get to the person, or particularly if something they come back and they had a friend who got breast cancer and now they're more interested, even if there's no change in their family history. Yeah, I agree. So and in getting a negative result, also, some of the risk stratification calculators that determine types of testing and screening frequency, if you can put in there that it's negative, you actually could maybe save yourself MRIs and some testing that you would otherwise be getting without that family history component, so or the genetic component.
SPEAKER_02:Myriad adds a risk score that is designed just for breast cancer. And I think they used RNA and DNA. I used to call it little SNPs, but they've developed a test that uses tire acoustic and uses these RNA gene segments, and they are pretty good about estimating the risk of breast cancer.
SPEAKER_03:All right. Well, thanks for being on. And we could talk all day about ACOG stuff, but but yeah, we appreciate your career. We appreciate your work with MedMal, and we appreciate your work certainly with helping us with reducing the number of obstetricians who hopefully have been sued for cerebral palsy cases with the work you've done. So Yeah.
SPEAKER_02:I wish we could do something better.
SPEAKER_03:But yeah. The fight goes on. The fight goes on. Alrighty. Well, thank you very much.
SPEAKER_02:Thank you, Harry. It's a pleasure.
SPEAKER_00:Okay, we're back. So let's go ahead and talk about that New York Times article about fetal heart rate monitoring. It's gotten a lot of circulation since it came out and since you made that recording. So so again, this was published on November 6th, 2025. It's called The Worst Test in Medicine is Driving America's High C-section rate. And I'm sure a lot of our listeners have at least seen this, if not read it. It depends on if you guys subscribe to New York Times or not, but but it has made the rounds out there.
SPEAKER_03:Yeah. All over social media, at least the social media that we live in. And a lot of our patients, I think, too. It's certainly a provocative title. But I also think that the core point of this article, well, it's certainly not unknown to most OBGYNs. It goes into the history of fetal monitoring and dives into how we adopted this tool into practice without a lot of good evidence or really any what we would consider good evidence today for getting FDA approval or adopting something like this. We just did it because it made sense. There's a lot of these things that we talk about that have entered into our fields because it made sense to somebody, and then it's so hard to undo those things later on. But continuous electronic fetal monitoring has done little, if anything, to improve perinatal outcomes. But yeah, it's become a large driver behind the number of cesarean sections that are performed. We've talked about this quite a bit before on the podcast, and it's interesting to me some of the reactions that I've seen on social media. I do think there's a couple of things that are important to level set about this. The first is that the choice of continuous electronic fetal monitoring versus intermittent monitoring is really just for those low-risk, non-augmented deliveries, which are a surprisingly small percentage of our deliveries. When you think about all the patients, this is not for inductions or people who have certain risk factors or people who've had certain issues. So it's not like this affects 100% of the population. The second thing I want to point out before we discuss it is the difference in continuous fetal monitoring versus intermittent fetal monitoring in that population of low-risk women and what is its impact on neonatal or perinatal outcomes. There's some debate about this. We definitely know it's associated with more cesareans. That part's not controversial. But in terms of neonatal outcomes, well, there's a Cochrane review that says that continuous electronic fetal monitoring is associated with a 50% reduction in neonatal seizures. Now, that's in this population of low-risk pregnancies. But there is no statistically significant reduction in perinatal death or in cerebral palsy. That same review, of course, says that it's associated with an increased risk of both cesarean and operative vaginal deliveries. Now, that's different than saying that no fetal monitoring is appropriate. Like this is not fetal monitoring versus nothing. Or the idea of doing fetal monitoring altogether is bad, but that's sort of the reactions I've seen on social media, which seem to imply in response to this New York Times piece that all fetal monitoring is bad in all situations and it should go. It's also a different conversation completely when we're talking about those higher risk deliveries or the patients who are augmented with oxytocin or inductions. And that's the other thing that I've seen on social media is that people are just lumping all this together and assuming that even if they understand this is about intermittent fetal monitoring, well, then intermittent fetal monitoring is what you should ask for all conditions in all circumstances. So the context of this conversation is really just about low-risk, unaugmented deliveries.
SPEAKER_00:Yeah, that's I've always thought that was interesting. So at least for these low-risk patients, they get less seizures with continuous monitoring, but not any other neonatal outcomes, death or cerebral palsy. So that makes me think that neonatal seizures mean nothing in the long term.
SPEAKER_03:Or not all seizures lead to cerebral palsy or I mean, it's we could spend an hour talking about, and Dr. Waldeman and I, of course, hit on most cerebral palsy is not due to hypoxic ischemic encephalopathy. Yeah. It's a much more complex pathophysiology than trial lawyers would have made it. But but we could reduce the seizures, but we didn't make a difference in a cerebral palsy.
SPEAKER_00:But at the same time, more cesareans and operative deliveries, so a lot more morbidities for the mothers for sure. So this New York Times article kind of glosses over this fact. But at least the facts are presented correctly. Just some of them are kind of glossed over there. It does say that so it says fetal monitoring decreases the rare seizures, but doesn't change the risk of long-term neurologic in injury. But they don't contextualize this very well in that it only applies to that very small subset of low-risk spontaneous labors in the U.S.
SPEAKER_03:I think it's a great article. I don't have any great disagreements with it.
SPEAKER_00:Yeah.
SPEAKER_03:But those are the numbers. I I'm just really responding there to how people on social media have over-generalized the conclusions of it. But that being said, the reason why continuous fetal electronic monitoring increases the risk of operative delivery in whether cesarean or forceps or vacuums in these low-risk pregnancies is because we're simply overreacting to some of the findings on these fetal tracings. So we are massively over-treating category two fetal tracings. So the fact that we're over-treating category two tracings is true not just for that low-risk population who could be subjected to intermittent monitoring, but also for the high-risk pregnancies, where removing continuous monitoring isn't a good option because there are improvements in other outcomes for those high-risk patients. So my thought is that we can make progress by doing less monitoring, yes, for those patients and therefore not having the information to respond to, not seeing the tracing that we're over-reacting to. But we could make more progress if we just learned how to respond correctly to this data that we're seeing. And then that would impact both the cesarean rate in the low-risk patients, but also the high-risk patients who we need to monitor.
SPEAKER_00:This article does a lot to address the perceived downsides of intermittent fetal monitoring, even for the low-risk labors, which is lawsuits, or at least the fear of lawsuits. And of course, if we've all collectively been overreacting to category two tracings, then and the fear of just landing with a brain-damaged baby and a lot corresponding lawsuit, it undoubtedly drives that overreaction tendency. That gets back to the conversation you just had with Dr. Waldman. So they did point out in this article that the big indication for cesareans in otherwise healthy pregnancies is fetal distress, or as based on our interpretation of the tracing. And this is significantly more often cited as the reason for cesarean than any problem with labor, like labor arrest or slow labors. And then in the article, they also do kind of highlight why we're so afraid of this. There's some horrendous lawsuits. There was a$48 million verdict in Missouri, a$950 million verdict in Utah. And then, and we won't go into the details about that, but then they did mention a just over$200 million verdict in Pennsylvania, and they did say that was based on the tracing, even though the blood gases, the cord blood gases were normal. But because there was a bad outcome, even despite the normal cord blood gases, they picked out something in the tracing and blamed it on not doing a cesarean early enough for that tracing, and they won.
SPEAKER_03:Yeah. And we don't know all the facts of those cases. We don't have the records or things like that. But it's alarming to think that a fetal tracing was used to reach such a horrendously large settlement when there was a normal blood gas. One of the things that Dr. Waldman mentioned that he worked on during his ACOG presidency was the ACOG document on neonatal encephalopathy, which tried to define some criteria for blaming neonatal neurologic abnormalities like cerebral palsy on events that happened during the labor or intrapartum and how that might correspond to things on the fetal tracing. And one of those criteria definitely is an abnormal blood gas. And apparently there wasn't an abnormal blood gas in this case in Pennsylvania that led to an over$200 million settlement.
SPEAKER_00:Yeah, like that really just shouldn't happen.
SPEAKER_03:It's a nightmare.
SPEAKER_00:Yeah, yeah, exactly. And these kind of lawsuits threaten women's access to obstetric care. We as a profession, we went through a period of time before that neonatal encephalopathy document existed where the lawyers could just make up anything to convince a jury that this was the OB's fault. And there were all kinds of these brain-damaged baby lawsuits everywhere. And that led to a near doubling of the cesarean rate in the US. And doctors just became more and more scalpel-ready in an attempt to save their careers and save their skin from these aggressive malpractice attorneys. But that evolved into a relative period of stability and maybe even some improvement when different states passed some tort reform bills. And then when that also because that document came out, fewer of these lawsuits were actually making it through successfully because now we had criteria that's more objective than just the fetal tracing. And so they couldn't just look at the tracing and say, okay,$900 million to this plaintiff. But then you read about those cases in New York Times and it feels like backtracking a little bit is just surreal and not a good way for obstetricians.
SPEAKER_03:Yeah. For it with the test, it has a 99.9% false positive rate.
SPEAKER_00:Right.
SPEAKER_03:And the number of malpractice cases, and in particular the size of the settlements, has been increasing dramatically in the last five years as the sort of industry of plaintiff's attorneys is growing rapidly in the U.S. by double digit percentage points every year. And as you said, this threatens to drive even more OBGYNs out of practice, but it also threatens the hospitals. A lot of those dollar amounts, obviously, are directed towards the hospitals, not just the doctor. And hospitals with smaller units in rural or underserved areas, they'll find it increasingly difficult to justify paying the sort of insurance premiums or just being self-insured for that matter, to stay open or to deliver obstetric services. There's at least some compelling data that the cesarean rate is as much as 20% higher in states with higher malpractice premiums than in those with lower malpractice premiums. Of course, lower is a relative word for OBGYN malpractice premiums. And that's, of course, already a cesarean rate that's likely too high in every state. But we know that the more pressure there is for malpractice premiums, the more cesareans you see. And that's likely related to over anxiety about a test that has a 99.9% false positive rate.
SPEAKER_00:We previously discussed some of these issues with fetal monitoring way back season three, episode eleven. So listeners can check that out for a discussion about the science behind this monitoring and what this New York Times article is discussing.
SPEAKER_03:Well, I'll also put a link to an article that was in obstetric synchonyology open access, the new open access version of the journal in April of 2025 this year, called Misinformation and Junk Science in Obstetric Medical Malpractice by Michael Ross. So this is free to read, even if you're not a subscriber because it's in the open access journal and it's definitely worth looking at, looks at three or four areas that often comes up in medical malpractice lawsuits, not just fetal distress, but also shoulder dystocia and some other things. But Dr. Ross notes that in a review of 2,151 cases that they could search for and find fetal hypoxia as a claim, the kind of thing that this New York Times article is looking at, there were 735 settlements with an average of 3.38 million dollars, 368 plaintiff verdicts with average award of 19 million dollars, compared to only 274 defense verdicts, where of course there was zero dollars. These sorts of numbers, they may be coming back with a vengeance in this sort of renaissance of plaintiff attorney cases. And it's all the more reason why Dr. Waldman's ideas from two decades ago in New York state really should be implemented on a national level. If OBGNs want to be able to practice with psychological safety and patients want better outcomes, like less cesareans performed unnecessarily out of unfounded fear from this test and other things too, then we've got to fix this issue. And certainly Dr. Woolman has been a thought leader in how to do that. But zero interest from state legislatures in actually realizing progress in that regard. So we have to list plaintiff's attorneys as a threat to women's health as these sorts of lawsuits drive out access and contribute to more cesareans and things like that. A contributor to maternal mortality in the United States are plaintiff's attorneys.
SPEAKER_00:There you go. Well, all we can do is get active. Get active vote if it ever comes up for but advocate. Well, well, thanks for Dr.
SPEAKER_03:Wallman being on, and we'll see everybody in a couple of weeks.
SPEAKER_01:See you then. Thanks for listening. Be sure to check out thinking about obgyn.com for more information and be sure to follow us on Instagram. We'll be back in two weeks.