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 11.12 The Malpractice Crisis Is Real And Blaming Evidence-Based Care Makes It Worse
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We push back on the idea that obstetrics “deserves” a malpractice crisis and explain how bad incentives and junk science can turn normal evidence-based care into courtroom blame. We also break down a few widely shared clinical myths and new research so we can practice with clearer eyes and less narrative noise.
• placental grading on ultrasound as low-value data with poor predictive power and high reader variability
• how malpractice commentary can seed plaintiff-friendly arguments against evidence-based off-label use
• why blaming misoprostol or “high-dose” oxytocin oversimplifies multifactorial outcomes
• quality improvement bundles as useful tools but weak proof without controls or causal clarity
• how massive verdicts and paid expert testimony can clash with modern science on cerebral palsy and HIE
• the FAA’s five hazardous attitudes and practical antidotes for high-stakes clinical work
• new data on LEEP versus cold knife cone for CIN, recurrence, HPV clearance, and access tradeoffs
• genetics and BMI as major drivers of gut microbiome patterns, not influencer narratives
• what a 1993 Doppler trial can and cannot prove, plus why replication changes conclusions
Be sure to check out thinkingaboutobgyn.com for more information and be sure to follow us on Instagram.
0:00 Welcome And Season Update
1:15 Placental Grading Myth On Ultrasound
6:44 Calling Out A Malpractice Influencer
14:06 The 2011 Policy Bundle Examined
23:20 What Drives The OB Malpractice Crisis
30:00 How Mega Verdicts Get Made
36:59 Five Hazardous Attitudes From Aviation
44:31 LEEP Versus Cone For CIN
48:04 Genetics And The Gut Microbiome
52:17 Does Doppler Ultrasound Harm Babies?
1:00:37 Recommendations And Closing
Follow us on Instagram @thinkingaboutobgyn.
Welcome And Season Update
SPEAKER_00Welcome to Thinking About OBGYN. Today's episode features Howard Harrell and Antonia Roberts discussing medical malpractice and more.
SPEAKER_01Howard?
SPEAKER_02Antonia?
SPEAKER_01What are we thinking about on today's episode?
SPEAKER_02Well, we've got a ton of stuff to talk about. You know, season 11 is quickly coming to a close. Can you believe we've been doing this for 11 seasons? There's there is one more episode, but that means we'll be starting season 12 very shortly.
SPEAKER_01That's crazy. And because we're modern physicians, we don't take breaks. So there's no break between seasons. It just runs into the next season. It's transparent.
SPEAKER_02In retrospect, we should have just numbered the episodes. Yeah, maybe.
SPEAKER_01But 13, yeah, you guys can do multiplication, 13 episodes per season.
SPEAKER_02Times 12.
SPEAKER_01Yeah.
SPEAKER_02Or times 11. Triple digits now.
SPEAKER_01So it's cool.
SPEAKER_02Well, we mentioned last time you and I were together that we were going to talk about the med malpractice crisis in obstetrics. And we have some other stuff to talk about as well. But we should also do a thing we do without evidence for today.
Placental Grading Myth On Ultrasound
SPEAKER_01Yes. Listeners love these. And we have no shortage of them. So we should do them as regularly as we can, really.
SPEAKER_02Alright. Well, why don't you give us one?
SPEAKER_01Okay. How about grading placentas on ultrasound and intervening on it somehow? So it's fairly common to see obstetric ultrasound reports that mention the grade of the placenta. I do see it pretty frequently. And that this becomes as a listed indication for either increased monitoring during the pregnancy or for just inducing labor. But is there any evidence that this matters? And should we actually be changing our management of the patient because of a placental grade that's on the ultrasound?
SPEAKER_02Well, this refers to the Granum grading scale. Granum was the doctor that first wrote about this in, I think, 1979. And it's based upon the idea that as the placenta matures, there are calcium salt deposits within the villi and along the septa. And this creates some bright spots that you can see on ultrasound or egenic densities. So a grade zero is an immature placenta. You typically see this in the latter part of the second trimester, where the coreionic plate is smooth, the placenta is uniform, and there's no calcifications. Then a grade one, you typically see it 30 to 32 weeks, and you start to see some indentations in the corionic plate and some punctate echogenicities. And then grade two, you see after 36 weeks where the indentations deepen, and you see a notched or wavy appearance there, and you get larger echogenic densities. And then grade three or a mature placenta, which you typically would see after 38 weeks, these indentations will go all the way down to the basal layer, and it makes the placenta appear divided into, well, cautyledons or distinct sections, and then you see more irregular calcifications.
SPEAKER_01Yeah, so already one point of education here is that at full term, grade three is normal, not like, oh no, that they're gonna placenta's about to abrupt or something. No, it's normal. So yeah, so when Granham introduced this idea in the 70s, he he it was thought that grading the placenta could potentially be a proxy for fetal lung maturity that was at the time determined by amniocentesis and doing a test of the amniotic fluid, because those placental grades did tend to correspond to certain weeks of gestation. But unfortunately, that turned out not to be reliable at all. A lot of pregnancies back then were still much more poorly dated because they didn't have really routine first trimester ultrasound. So this was one way to help determine even is this 36 weeks or is this 34 or where are we? But then this placental grading got extrapolated to the idea of hypermature placentas that could be associated with petal growth restriction or hypertensive disorders or other problems that we might lump under the term placental insufficiency. So then the idea here was that if we saw grade three maybe earlier on, like at 32 weeks, then we'd think the placenta is aging too quickly. There might be an increased risk of stillbirth.
SPEAKER_02Right. And this was at a time when ultrasound was still very poor quality. This is 1978, 79, the year I was born, 78. And we didn't do things like certainly like umbilical artery doppler indices to measure the actual vascular resistance and blood flow, and we didn't have biophysical profiles and things like that. So this became something that people worried about when they saw it as a sign of premature placental aging or hypermaturity, as you said, and therefore a compromised pregnancy. But it actually had incredibly poor predictive value. And really, in modern obstetrics, it just has no meaning or place in light of things like Doppler velocymetry and biophysical profile and the things that we do today to assess this.
SPEAKER_01It may be that the pathophysiology that leads to those changes that are visible on ultrasound in the placenta could be accurate, but the predictive and prognostic value of that numerical grade score is just such poor quality that it doesn't have any true clinical utility. And that particular grading system is subject to a lot of interobserver variability, and that could be one of the things that makes it so unreliable.
SPEAKER_02Yeah, we can put a link from a 2011 study that showed that even experts had very limited agreement about what grade a placenta was. And this idea gets revisited every now and again because it's an easy research project for fellows and residents. There's a lot of things like this, how frequently or how tight the coiling of the placenta of the umbilical cord is, how thick the placenta is. There's all kinds of data that we can measure with ultrasound, and we and it's fair to do experiments and see if it has some meaning clinically and if it ever becomes useful. But otherwise it's just an interesting thing. And so I think of it like the Chadwick sign, which people for some reason are still pimping med students about. It's a thing, sure, but it has nothing to do with how we diagnose whether or not another person's pregnant anymore. It's just not useful.
SPEAKER_01All right.
Calling Out A Malpractice Influencer
SPEAKER_01Well, let's move on. So we've talked offline several times about an obstetrician out there who is on Substack. The it's like people that don't know it's basically a blog, uh social media kind of thing. And his articles get shared quite a bit on the OBGYN version of Doximity. And so I will open up Doximity and frequently see these articles. And this guy makes a lot of arguments that we take issue with quite strongly. So we we wanted to talk about that in relating to the topic of malpractice. So usually if there's an influencer who promotes disinformation, we want to avoid giving them any extra traffic. So usually we're not gonna call them out by name. But this person we're just gonna call out by name because it goes a little bit beyond disinformation. So his blog is called Obstetric Intelligence. He's a doctor named Amos Grunebaum, and it has become very prevalently featured on Doximity. Even when I click the little option of don't show me this anymore, or even submit a complaint on Docsimity, it keeps showing up. It just is very persistent for some reason. So I'm sure lots of other Docsimity users see it as well. It's seems to be pretty popular. And the things that he says in these articles seem like they would be very beneficial for plaintiff attorneys, and especially the kind who attack good care and conscientious doctors and are getting a big payout. And so we're just gonna bring him up because it seems like he undermines individual doctors and even medical societies like ACOG that are striving to do a lot of good for a lot of patients based on objective data. So hopefully, if any of our listeners see these articles pop up, they don't immediately think that here's an MFM, he's held leadership positions in a big hospital. I probably should listen to what he says. Also, I would say ask yourself why would a doctor sell out the rest of his specialty like this? And we'll get into the examples. So maybe underlying this is someone that got burned by a bad lawsuit and became cynical, or potentially is an expert witness for these plaintiff lawyers and is getting their payment for that. So anyway, it is a little disappointing that Doximity is promoting these types of authors and accounts. So the first post of his that I ever read, I think outrageously advocates for obstetricians to stop using Cytotech for labor induction or cervical ripening because despite all of the evidence, it's really just undeniable that it's a safe, effective method of cervical ripening, labor induction. It's endorsed by ACOG for decades now. He's already arguing that it doesn't have the FDA labeling for that indication. He claims that for that reason, any obstetric lawsuit involving cytotech, or maybe by extension, any off-label use of any medication, even if it's evidence-based, the lawsuit should win if someone's being sued for something that involves using off-label medications. So in May 2026, there was another one of those articles of his, and it was called Malpractice, Crisis, Obstetrics Itself.
SPEAKER_02Yeah, this is all complicated, and there's a discomfort that we both shared in like naming someone and talking about him in this way. And certainly we don't know what people's intentions are, and we're not psychologists or psychiatrists. He has worked for plaintiff's attorneys over the many years, and some of his testimony has been thrown out by courts and things like that. So I don't know what his motivations are. But in Doximity, they share a lot of things that are essentially blogs, and people click on them. People stop to watch car wrecks, too. So they feed people what they want to see, just like our social media feeds do. I'm not sure what their selection process is or how they decide what they share, but we do have a resurging malpractice crisis in obstetrics, and it's not one that we built ourselves, as he claims in this new piece. It's one that's being egged on by a growing trial lawyer industry in the United States. There are currently, as we've discussed before, more types of all personal injury lawsuits that are going on now than there were a few years ago. It's a growth industry for trial attorneys. We previously discussed that this is growing now by double-digit percentages every year for the last several years. In the medical arena, unfortunately, obstetrics tends to be the tip of the spear for med mal or for liability lawsuits. And so we're seeing an uptake now in medical malpractice lawsuits and certainly in the size of the settlements. And this has probably worsened since COVID. And in the age of TikTok and social media, there's become this swelling distrust for science and for the medical establishment in particular, and then just massive widespread disinformation about birth and obstetrics in particular. But the number of obstetric lawsuits, and again, the sizes of the settlements are both increasing in a way that's very reminiscent of 25 or 30 years ago when we really got in trouble. And the tone of his article and others like it is something that this is something that we've brought upon ourselves is frankly not helpful.
SPEAKER_01Yeah, so he wrote this in response to an AMA report that said the obstetric liability premiums have risen for seven years in a row. And he starts out with this story of, I don't know, a real or a hypothetical case where patient was induced with side attack and then oxytocin, which he argues starved the baby of oxygen, but made the staff happy because her cervix dilated quickly. And then there was a shoulder dystocia. And he says, minutes passed, don't know how many, but then that the child was permanently brain damaged and developed cerebral palsy.
SPEAKER_02Well, we don't, as you said, we don't know if this is a real case or something, a straw man that he made for his article. We don't know. There's no discussion of the fetal heart tracing. We don't know if it's real. But the way it's written implies both that there's something wrong with mesoprostal or side attack, and something wrong with what he calls high dose oxytocin, which I think you and I would probably call normal dose oxytocin. And he seems to claim that the child suffered hypoxic, ischemic, encephalopathy even before the shoulder dystocia that then lasted several minutes. So I'm not sure what he's implying the cause was. But he does all of this to argue that he has some successful ideas for preventing obstetric lawsuits.
The 2011 Policy Bundle Examined
SPEAKER_02And indeed, he wrote an article about this in 2011 about a quality improvement project that he did at his institution. And this was published in the Gray Journal at the time. And he argues that this publication, in fact, is proof that he knows how to not get sued and how to avoid sentinel events. And essentially, he's got the secret sauce for preventing fetal injury, and the rest of us are ignorant.
SPEAKER_01Well, specifically, he says things they did there with their quality improvement included banning mesoprostol for labor induction because it's not FDA approved for that. And he claims that it's associated with irreversible uterine tachycystole. There's no role for turbutylen or anything in there. And then they also implemented a standardized essentially low-dose oxytocin protocol where they started at one milliunit and increased it by one milliunit every 15 minutes or so, and then would have a hard stop at 20 milliunits. Then they would stop the oxytocin for things like elevated uterine resting tone and other indications that are not evidence-based. And then they added a laborist and no longer allowed attendings on call to cover GYN if they were also covering obstetrics. So then they added a GYN-only call person. Some of these are not necessarily bad in an individual context, but this is just part of the whole package. Then they also gave routinely some kind of chemical anticoagulation to everyone who got a cesarean. And then there there were some other things in there as well. I think those were the highlights.
SPEAKER_02They only use pumps to run oxytocin, which is fairly standard nowadays, having color-coded labels for the pre-mixed solutions that would be administered IV, instituting a chain of command and other what we would call crew resource management and teamwork stuff. And most of that is fairly standard today. It wasn't necessarily standard 20 years ago. And their conclusion of this paper was that they reduced their average yearly compensation payments from $27 million a year between the years 2003 to 2006 to just $2.5 million a year from 2007 to 2009. But of course, the problem is that this paper is not scientific. This is a case report of what happened at one institution with no controls and no standardization and no potential to show causation from anything, right? It's not science. So the reason why, and this is what happened here, by the way, the reason why a hospital goes out and hires a consultant and does sweeping changes to every possible thing that they can think of at the same time that could be a potential source of litigation is because they had a six-year time period where they were paying out $27 million a year in my practice settlements. This is one unit. And that, of course, is an extraordinary amount of money, and that's 20 years ago. Extraordinary amount of money. So to have that kind of dollars spent represents probably a handful of really bad cases in a very litigious New York environment, which we discussed before also on this podcast. So a whole lot of things change when that happens in a reaction to that run of potentially bad luck, potentially some bad doctors, potentially some just really sad and unfortunate circumstances. We don't know. And a lot of things change that probably do change for the better and improve outcomes by some degree. So I'm sure many of the changes might have been in response to a particular case. I can imagine that they, I don't know, I don't know any of this, but I can imagine that they had a case where the attending was distracted with a GYM patient and somebody needed a cesarean and they only had the one attending and there was a bad outcome and something like that happened. And you can imagine many other reasons why they chose some of the interventions they chose, maybe communication issues between the nurse and the physician, or who knows. But it's certainly not scientific to say that if your hospital adopts a whole bundle of interventions and policies and procedures, that you'll automatically you're basically guaranteed to see a reduction by 90% or more in your obstetric malpractice payments. That is not science. It's not even a case controlled study, it's just an antidote. But even if you did show with more scientific methods that this bundle of interventions and policies could lead to fewer bad outcomes and fewer claims and settlements, it's still another leap of bad science to claim to know which of the things in that bundle were the difference makers in those negative outcomes.
SPEAKER_01Right. So for this article, why single out mesoprostal and oxytocin that he calls high dose, that is really just standard? Why pick those things and claim that those were what caused cerebral palsy in a case that had, you know, a thousand different inputs along the way and data points? It's much more likely that standardizing electronic fetal monitoring terminology and improving communications and crew resource management probably were what led to preventing some of those catastrophic outcomes that they previously had that had been causing these multimillion dollar obstetric payouts.
SPEAKER_02Yeah, usually when there's a significantly bad outcome that's actually due to something that occurred in the hospital, it's multifactorial and there's lots of causative and putative causes involved, and it's always a trademark of bad litigation that some expert reduces it down to one thing. One thing was the cause of it. And without that one thing, everything would have been okay. If they had only done the cesarean 27 minutes sooner, everything would have been normal. When life is way more complex than that, and that's just a hallmark of the way the legal system works, unfortunately, but it's bad. I think the reason why a person, though, would focus on those issues like mesoprostal or so-called high dose oxytocin rather than maybe communication issues or just human error is because it's depersonalized. When you focus on issues about communication and clinical judgment by the nurses and physicians, especially when these people are your coworkers, well, that feels much more uncomfortable than blaming dangerous medicines that you've been tricked into using by ACOG. But now you know better. Now you know if we just never use mesoprostal and never started oxytocin by more than increased by more than one milliunit every 15 minutes, we would never have these problems.
SPEAKER_01Right. So if a patient had what we would call a category three tracing for a prolonged period of time, and then the newborn had hypoxic ischemic encephalopathy or cerebral palsy, and it was tracked back to that, then in most cases you'd conclude there should have been a team response to that tracing, or that information should have been communicated and acted on in a very prompt manner before the damage was done and not let it keep going on for however many hours. And again, in this article, in this little hypothetical story, there was no discussion about the tracing or the nursing interventions. Did they try to reposition? At what point did they call the provider? What did the provider do? So if this story happened in a ward that has poor communication and maybe a fear of reporting, or just not a well-established chain of command, or just a lot of incompetence, but they don't want to confront those ugly truths when they're looking into their root cause analysis, then it's easier to say that category three tracing was caused by the oxytocin. So we should just switch it to the low dose and then problem solved. And then that they're not looking into the mishandling of the clinical situation, but they're protecting their pride without really improving themselves or their team.
SPEAKER_02We'll put a link to that 2011 article. And there are some good things in it. Again, most of which have been adopted routinely across the country over the last decade or so. But you have to read it with the knowledge that some of the things in this bundle of interventions might have been useful, like improving terminology, communication, things like that. And some might have been neutral, maybe didn't make a difference at all, and some might have even been harmful. It is not a scientific paper. Now, I'll point out three or four things. We've been talking around these,
What Drives The OB Malpractice Crisis
SPEAKER_02but three or four things specifically. And I think this gets us back to how this new blog item he wrote that basically blames obstetricians for our malpractice crisis rather than the plaintiff's attorneys, and the anti-science and anti-physician sentiment that exists in the United States. So the first one we've been discussing is mesoprostal. He advocates for a ban of this medication. But when he does that, he's saying that all the scientific literature about it and the practice bulletin from the American College of Bostricians and Gynecologists that now recommends it as a preferred cervical ripening agent, they're all just wrong. And that's just hubris. He's the only one right. The next one is again what he calls high dose oxytocin, which again is just what most of us do is normal. It's not high dose. Our literature and our recommendations from our professional body tell us that the higher doses are safe and effective. So he once again disagrees with everybody and he knows better than randomized controlled trials and science. And this puts him in the camp of being anti-scientific, and worse, his words will likely be used, and they have been used, we know they have been used, against someone in court somewhere, if he doesn't himself offer to testify against an obstitution, doing normal and safe care because he's taken things that are normal and safe care and told the world that they are abnormal and dangerous and the sign of reckless behavior, essentially. Another one is routine thromboprophylaxis for cesareans. So we discussed that literature quite a bit recently. And of course, we have very good evidence that it's not indicated for most patients who undergo a cesarean and doesn't seem to reduce the risk of thromboembolism and just increases the risk of wound infections. So again, he knows better than organized science.
SPEAKER_01Yeah, and there seems to be some sour grapes in this blog post stating that after he left the hospital that he was working at and did this program, the hospital started using Musaprostol again. Oh no. And then he also seemed a bit bitter that not every hospital in the country has adopted this bundle of changes. And that seems to show, like, maybe a lack of insight that maybe this experiment proved nothing and that hospitals did actually adopt many of the good things in this or other similar quality improvement bundles, but left out the bad things that were also in there, like banning a recommended drug.
SPEAKER_02Right. Well, and lastly, he talks about the American Medical Association again calling, oh gosh, for economic caps and tort reform in response to this new crisis that we're facing of medical liability lawsuits. And of course, we've discussed tort reform as an essential part of keeping obstetric units, both urban and rural, open, but especially in smaller hospitals, or in hospitals that are often serving underserved or under-resourced, I should say, patients, even in big cities. But he essentially argues that we don't deserve caps on damages because we haven't adopted his recommendations.
SPEAKER_01Yeah, he says the profession of OBGYN that has declined to do the work of prevention, which is basically do his bundle, is what he thinks that means, has not yet earned the right to have legal protection from its consequences. So I think this is probably the most infuriating of all of his points so far, like the most just egotistical, because these types of just uncapped damages and the threat of bankruptcy and shutting down does not incentivize, it doesn't serve to make doctors be like better doctors that now now I care and pay attention, but before I didn't. It just makes them more fearful and paranoid. And then it still actually causes a lot of good doctors to get basically an unfair verdict against them. And it can ruin their career, and it can have so much other just really negative outcomes. And it really doesn't help the patients either. We could go into this, we could probably get lost in this of why it's so bad. But one thing he does not mention in these blog posts is how much the plaintiff lawyers are getting a cut out of these payouts because they're not just exploiting the medical system and the providers and doctors, but also the patients who maybe had a really heartbreaking outcome and don't realize that when they're approached by one of these lawyers who act like they're gonna, I'm gonna fight for you, the lawyer stands to make a huge cut of whatever that settlement might be. And so if they can just argue that this good and reasonable care, if they can just argue that it was actually negligent and it caused the bad outcome, then they're profiting off of the patient's loss. And so to make those kind of arguments, they just need people like this guy who are willing to contradict very solid, well-established science, even when they're sitting there under oath.
SPEAKER_02For the right price.
SPEAKER_01Yes, for the yeah, the that's the These witnesses are paid.
SPEAKER_02Yeah. Yes. I if you happen to use mesoprostal or normal dose oxytocin at you know, something more than one milliunit at a time, he's certain that you're such a dangerous person that you deserve to lose your house and be bankrupted. But we discussed some of these large settlements earlier in the season, including a huge settlement where the blood gases and the tracing were normal. And the science has moved to show that if anything, the fetal tracings are very poor predictors of hypoxic, ischemic encephalopathy, and that even blood gases themselves don't mean exactly what we thought they meant 10 to 15 years ago. They have poorer predictive value, both good and bad, than we thought that they did. We live in an age where the science says that well over 90% of cases of cerebral palsy are due to something other than intrapartum events. And even when it is due to an intrapartum event, many of these are unpreventable. So this sort of writing is just not helpful, and it's in conflict with the current science and with the needs of obstetricians and gynecologists and the patients who rely upon them to receive quality and responsible care.
SPEAKER_01Yeah, somebody in Doximity needs to realize what this is and just
How Mega Verdicts Get Made
SPEAKER_01stop promoting it.
SPEAKER_02Yeah. He'd written a previous post that I know you and I talked about offline about this $200 million verdict in Pennsylvania. And again, he essentially implied in his writing on that verdict that this was a preventable outcome if the hospital had adopted his protocols. And he does have a history, as I said, of being a plaintiff's expert witness in court. And so these sorts of things are consistent with testimony he might give.
SPEAKER_01Yeah, and we never know all the details of these cases, but in that $200 million Pennsylvania verdict, it actually started off $183 million and then was later increased to $207 million. And we know there was a diagnosis of choreo ammunitis during a labor induction, and eventually there was a cesarean, and the plaintiff's witnesses argued that it was ordered too late by 35 minutes. And because of that 35-minute delay, the child developed profound cerebral palsy. And the jury decided it there would need to be $101 million to take care of the child's medical needs for the rest of his life. And then they, on top of that, awarded $80 million in non-economic damages and $1.7 million for lost wages. And in the appeal, which was not successful, the defense argued that plaintiff's attorneys manipulated the jury by talking about the $51 million salary of a pro football player. But in any event, these numbers are just mind-boggling, and it's a pretty extraordinary set of circumstances that would that could make 35 minutes be that important. Maybe if it was I would I could hypothetically come up with how that could happen, but but it seems like probably a stretch here. And again, we don't have all the facts. We don't actually have the tracing and those kinds of things, but sounds like there might have been some tachycardia, there might have been some prolonged four-minute-long D cells, I think.
SPEAKER_02Yeah. Well, we don't have all the facts, but I will say they went to court rather than settled prior to court. So that sounds like there were probably very favorable facts for the defendants. And this happened at one of the leading institutions and residency programs in the United States with a very good reputation and a very good hospital. So 200 million, it's hard it's hard to imagine. And it's hard to imagine that they wouldn't have settled it out of court if the fact case fact set was that bad. But again, neither of us are in any position to say whether malpractice did or did not occur based upon what we can glean from the public record. However, I would also say Dr. Grunbaum is under no more information than we are, yet he immediately convicts the staff and physicians of this, again, excellent OBGIN residency program as being clearly guilty. And the amount of that settlement is absolutely extraordinary. And settlements of that nature are meant to be punitive and to put some bad business, some evil corporation like a tobacco company, out of business for the for all the people they harm when they're of that size, not hospitals desperately working with limited resources to save lives in an under-resourced community. The idea that the University of Pennsylvania should be put out of business in the same way that a plaintiff's attorney might want to put out of business, say Philip Morris or something, or some other evil corporation that was knowingly selling a harmful product, that's just beyond comprehension to me. This case also featured a high profile expert witness for the plaintiff, we won't name him, who in other cases has disagreed with our established fetal heart monitoring nomenclature. He claimed in one case that a category two tracing should actually be considered a category three so that he could then apply management decisions that we normally reserve for category three tracings to a category two tracing. So this seems to me to be a bigger problem that maybe Dr. Greenbaum should focus on are the role of bad actors acting as plaintiff's witnesses. In that particular case I'm talking about, not the Pennsylvania case, but the other one, this expert, the same expert, he actually cited an article by Stephen Clark, and Stephen Clark then wrote an affidavit for the court and later testified in the case. And I'd like to read Dr. Clark's affidavit or a paragraph from his affidavit. He says, quote, to this day, the glaring absence of any valid scientific support for the appellant's causation theory remains an appellant's causation theory still is not generally accepted in the obstetrical or maternal fetal medicine community. Just recently, and before I became aware of this litigation, I published a scientific commentary rejecting the appellant' causation theory as junk science, because not only is that premise unsupported by the peer-reviewed literature, it squarely conflicts with the overwhelming weight of scientific literature on this issue. So the man that Dr. Clark is rebuking here is the plaintiff's expert in the $200 million Pennsylvania case that Dr. Grunbaum clearly believes was decided correctly and that caps are not appropriate. So in that other case that we're talking about that Dr. Clark was mentioning, the newborn had apgars of two and six and had no seizures, no sign of intracranial hemorrhage, no indication of organ dysfunction, it had normal head imaging. Yet the expert witness, this man who will remain unnamed, he concluded that the child's injuries were due to birth asphyxia. And that, of course, is contrary to our understanding of how hypoxicosemic concephalopathy is diagnosed and how it leads to cerebral palsy, given all of those findings I just mentioned. So keep in mind that this is the same expert witness in the pin case. And we don't have all the pin case details. We will eventually, as it becomes more part of the public record. But it doesn't look good to me considering that they the University of Pennsylvania took it to court and considering that this was the expert witness.
SPEAKER_01But he commented on them in his blog and just jumped on this bandwagon of attacking the doctors that he didn't have the details on.
SPEAKER_02Rather than the expert witness or the industry that's leading to these, yeah. Well, I did think of one other thing that's maybe relevant to this conversation.
Five Hazardous Attitudes From Aviation
SPEAKER_02Have you ever heard of the five hazardous attitudes?
SPEAKER_01No, I don't think so.
SPEAKER_02Well, this comes from the Federal Aviation Administration. It's part of standard teaching for pilots and more specifically for people who become instructors, pilot instructors. All of our pilot listeners can correct me about that if I'm wrong. So there's five of these principles that they try to highlight. So the first one is anti-authority. Don't tell me what to do. So this person resents or ignores rules or standard operating procedures and regulations.
SPEAKER_01Okay. So this would be like someone who thinks they know better than ACOG guidelines or other scientific literature.
SPEAKER_02Yeah. Okay. Yeah, you're learning quickly here. Okay. Okay. The next one is impulsivity. Do it quickly. Do something right now.
SPEAKER_01Okay. So like reactively adopting an unproven set of safety interventions that maybe sound like you're doing something good in response to one bad outcome, and then declaring that you've just invented a new standard of care.
SPEAKER_02Yeah. Something like that. Yeah. Okay. The next one is invulnerability. This would never happen to me. I'm just too good.
SPEAKER_01Okay. So that's that's like me saying, I'm the smartest doctor in the world. I can see things even that in fetal tracings that other people can't see. Or let's say I'm the best in the world at shoulder dystocia because I've always gotten them out so far in my one single experience. So I will never have a fetal injury and I will never, never have to get have to worry about a lawsuit.
SPEAKER_02Yeah. Okay, you're brutal. Okay, but yeah, the next one is similar. Machismo. I can do it. Watch me prove it. And this is usually driven by a desire to impress others or prove personal superiority.
SPEAKER_01Okay, so this would be like taking a very complicated obstetric case with tons of variables and unknowns and just distilling it down to one axiom, like a one-liner, and then patting myself on the back because I'm so brilliant to have come up with just that that one simplified axiom about this.
SPEAKER_02Yeah. Something like that. Yeah. Alright, the fifth one is resignation. What's the use? It doesn't matter what I do. I can't do anything.
SPEAKER_01That sounds defeatus. I'm not sure what to do with that one.
SPEAKER_02We do it when we don't stand up and fight for the change that we need. I think that's what we can do with that. Many of us view our situations as purely a matter of luck or fate, and we have this sort of attitude of passive surrender rather than active troubleshooting. Anyway, these five hazardous attitudes are so typical, well, of bad pilots who die in plane crashes, but also of many particularly older male physicians, but of physicians in general. So let me give you the anecdotes to them. The antidote to anti-authority is to follow the rules. They're usually right, or we'll change them as we go and make sure they're right.
SPEAKER_01Okay, so this would be like using mesoprostal at the suggested doses to induce labor, using oxytocin, managing category two tracings according to the best evidence, and then not giving heparin to every single cesarean patient.
SPEAKER_02Yeah, follow the rules. Okay, the antidote to impulsivity is not so fast and think first.
SPEAKER_01Yeah. Yeah. We should realize there's emotional bias associated with feeling this urgent need to take some immediate action without fully properly assessing the situation and actually weighing evidence and alternative options first.
SPEAKER_02Okay. The antidote to invulnerability is to acknowledge that it can happen to me. It can happen to anyone.
SPEAKER_01Yeah, yeah. I think no no one wants to really acknowledge that, especially the earlier they are in the career. It's just this painful thing to think about. But many of the most unfortunate outcomes in medicine are things that really could happen to any one of us, any one of our patients on any given day, that we're just going about our business at work, just doing what we always do, that we're what we're good at doing. These things can still come up. And many of these outcomes are unavoidable. And that can be just a terrifying thought. Yeah. So that's not an excuse just to admit defeat and just be cynical about it. We, of course, we need to be diligent about training ourselves, continuously learning, training our teams, building quality programs, but we do have to acknowledge every day that a certain percentage of deliveries will be shouldered socias. A certain percentage of those will have brachial plexus injuries and be difficult. A certain percentage of babies are going to be born with cerebral palsy. And as Dr. Clark points out, the rate of cerebral palsy, at least among term infants, has not declined despite cesarean rates going from five to five percent to above 30%.
SPEAKER_02Yeah. Well, okay, machismo, the antidote is to understand that taking chances is foolish.
SPEAKER_01Yeah, of course. But it's not taking a chance to use medications that have an incredibly safe track record like oxytocin and musoprostal.
SPEAKER_02Right. And the antidote to resignation is to realize that we're not helpless and that we can make a difference.
SPEAKER_01Yeah. And I, well, we called out someone in a more critical sense, but there's lots of people out there that are fighting the good fight. There's one that that I like a lot named Dr. Gita Penza. So that that's just a recommendation for her. She has a podcast called The L-Word. It's doctors in litigation. So you everyone should check that out. But these five hazardous attitudes, I think, were all great points. And that should become one of the many things that we adopt from the airline industry to improve patient safety. These should be taught even to students, definitely to residents. The these attitudes can be very problematic in a high stress, high-stakes environment. If there's an impulsive person that suddenly has heavy bleeding and they panic, they might just, in a frenzy, put on quickly put clamps on tissues before achieving adequate visualization and then cause more injury that way and more bleeding. Resignation often looks like people freezing up when there's a problem, like shoulder dystocia, instead of just taking a breath and then moving through their little checklist deliberately calmly. And then, of course, we see those anti-authority tendencies all the time, both inside and outside of emergency situations. People want to rely on their own instincts rather than follow proven best practices. So we have to anchor our decisions on the on clear, objective, evidence-based data.
SPEAKER_02All right, agreed, yeah.
SPEAKER_01Well, I thought you said this. We've talked about this for quite a while. Is this going to be the only to thing we talked about today?
SPEAKER_02All right. We can do a few other quick
LEEP Versus Cone For CIN
SPEAKER_02points then. So there is a paper I I wanted to talk about. A couple papers. There's a paper from JAMA Surgery published June 3rd that looked at two large cohorts from Sweden and China and compared the rates of recurrence of cervical lesions and clearance of HPV in patients who were treated with cold knife cone versus those treated with a LEAP procedure for CIN or carcinoma in site to so in the large Swedish cohort that had over 77,000 patients, most of whom got leaps, they were followed for 22 years, and they found a 21.2% recurrence rate in the patients who had LEAP procedures and the same recurrence rate in the group who had a cold knife cone, but the years didn't match up. So the per year recurrence rate was 1.89 per thousand in the LEAP group compared to 1.52 per thousand in the cone group. So the cone folks did have less recurrence. Most of the women in Sweden, as I said, had LEAPs. It was like 98% to 2%. In the cohort of patients from China, which was much, much smaller overall and only had a nine-year follow-up, there was a 1.8% risk of recurrence in the LEAP group compared to a 0.8% risk in the cold knife cone group. And the patients had a higher rate of clearance, the ones who had cones from HPV compared to the ones who had leaps.
SPEAKER_01Yeah, obviously, I think it should make sense that a cold knife cone is going to remove more tissue. Generally, you can just get deeper with the angle of the knife than you can with the little loop electrode. And that then it would have a higher rate of complete excision compared to a leap. But that's not the only consideration when you're choosing between the two procedures. We can think about outpatient versus OR setting can make a big difference for someone if they're still pursuing fertility. What would be their risk of preterm labor? What are the just the surgical risks? So there was an accompanying editorial in that same issue. It was co-authored by Jason Wright, who is the editor of the Green Journal. And so his editorial points out that we still don't recommend a universal preference for one method over the other, leap or cone, but we do recommend adequate depths of excision. So at least 10 millimeters. And then they point out that in-office leap procedures compared to usually in hospital or surgery center cold knife cones can really help sustain access to at least some kind of excision in a world where patients already face barriers to screening and prevention. And they also point out that HPV clearance rate is still very high for both methods. So doing one of them is better than not doing either of them. And they suggest that we should also be giving the HPV vaccine at the time of excision to close that gap. And of course, they point out that LEAP procedure does have a lower complication rate and a lower impact on future pregnancies.
SPEAKER_02Yeah, I was happy to see that they invited that guest editorial. So I don't think that this new article justifies everyone switching to cold knife cones immediately. But for example, if you don't have in-office capabilities for a leap and you're going to the OR anyway, and you have a patient who's not planning future pregnancy, then this information could be included in helping make a decision about which technique you're going to use. Okay, another article that I at least want to put on everyone's radar, this kind of stuff excites me.
Genetics And The Gut Microbiome
SPEAKER_02It's not strictly obstetrics, comes from Nature Genetics back in February. And this publication talks about the a subset at least, a group from a study called the Hunt Study. So we see tons of publications now and all kinds of stuff from the what I'll call the alternative health movement when cells pitches and functional medicine people talking constantly about gut flora and gut microbiota. Everything from probiotics and prebiotics to colon cleanses and detoxes and whatever foods and stuff are being sold. In some manner, the implication is that it's going to affect your gut flora. And lots of associative studies have shown that different gut floral are associated with different health outcomes and different human diseases. Now, virtually none of this stuff is ready for prime time. Probiotics, for example, have failed in replicated clinical trials to show really any clinical benefit. But it's one of those things that makes sense to people, so they try them and they spend their money on them. Now, the authors in this nature genetics study, they looked at the genetic factors that influence the gut flora in 12,000 individuals that were part of this hunt study, and they found 12 reproducible SNP species that were located in six loci. And essentially what they've shown is that your gut microbiota, your flora, has a significant dependence on host genetics. They also found that BMI is a significant determinant of gut microbiota composition. So I love this because it's another story of association not equaling causation. The underlying cause of many health conditions that have been associated with different gut microbiomes is likely genetic. It's rare that association equals causation, but it's common that we jump the gun and make narrative fallacies based upon associated factors.
SPEAKER_01Yeah. So essentially they found six genetic hotspots that are involved with the gut bacteria interactions. Two of these are already known, but then they discovered four new ones. And these genetics also change what the bacteria do. So it could be the same bacteria, but in two different people with the different genes, it does different things. So our genetics will influence, for example, whether a certain gut bacteria is equipped to break down or to build up specific molecules. And then they found that the same genetic variants that alter your gut bacteria are also linked specifically to conditions like celiac disease and hemorrhoids. And they also found that obesity causes change in the gut flora, not the other way around. They use Mendelian randomization to show that higher BMI actively causes changes in the gut microbiome, which this really should just settle the direction of that relationship. Because a lot of, I know a lot of alternative health influencers argue that obesity is caused by gut microbiome being a certain way. And in fact, it's the other way around. So this probably also explains why a lot of research that attempts to alter the gut microbiome in order to treat obesity has not resulted in improvements in in BMI or other disease states because the underlying problem is genetic.
SPEAKER_02I like stuff like this, one because we could do 10 episodes on false claims by functional medicine folks, but also because people get ahead of the science. And we talk about that a lot where we've not seen interventional trials or replicated interventional data that shows that an intervention makes a difference, and we get ahead of the science. I didn't throw in here, but you've seen the article that says that most of our microplastics literature is due to a contaminant in the gloves used to process the samples.
SPEAKER_01Yeah.
SPEAKER_02So that's a great example too. We could talk about that another time, but if people haven't seen that, look for it. But that's a great example too, where we get ahead of things really quickly. And that's why we wait for replication and wait for the science. And once we institutionalize some belief or whatever, it's hard to back away from that. So I'll tell you one thing I learned on social media
Does Doppler Ultrasound Harm Babies
SPEAKER_02though. I learned that ultrasound, or I guess Doppler, ultrasounds, Doppler specifically, is it causes fetal growth restriction. Did you know that?
SPEAKER_01Oh, apparently not. Apparently I learned something new today.
SPEAKER_02There you go. And apparently this is evidence-based. Really? So the videos and reels that I've seen claim that in fact ultrasound is not detecting fetal growth restriction, it's causing it. And it's not hypertension or microangiopathic diseases of the placenta or diabetes or anything like that. These experts give a link to a paper that appeared in the Lancet in 1993 that shows that it's the ultrasound, it's the Doppler specifically.
SPEAKER_01Okay, so the Instagrammers are practicing evidence-based medicine now?
SPEAKER_02Well, they like to cite random studies that they can find when it seems to suit them. So this study in 1993 was a randomized controlled trial that had 2,834 women, whom they randomized to a group that either received continuous wave Doppler flow studies five times from 18 to 38 weeks, versus a group that just got the single anatomic ultrasound at 18 weeks. And they had a total of, again, five of the ultrasounds in this intense group, and they were Doppler flow studies, not just ultrasound. And if you read the abstract of the paper, it says that they found a higher rate of babies born, so these are birth weights, less than the tenth percentile and less than a third percentile in the group that got the five Doppler flow studies.
SPEAKER_01Aaron Powell So it was something about the Doppler, specifically the Doppler test, not just any ultrasound that was Well, right.
SPEAKER_02Yeah. Yes, but those lines have been blurred. That distinction has been blurred completely for the audience of the social media posts. If you read the comments, these folks are ravenously acceptive of the idea of the absolute bona fide proof that ultrasound is harmful. It's undoubtedly part of a larger conspiracy. It's pretty extraordinary. But anyway, this study found no other difference in outcomes, just that more babies were born with weights below the 10th and 3rd percentiles.
SPEAKER_01So I guess they're trying to take down big ultrasound or big ultrasound. Yes.
SPEAKER_02Oh, they talk about how much money the machines make and how much doctors make off of them. Yeah, it's there it's ravenous. But I think studies like this are interesting. And this is another great study for a journal club for your residency program. So to the conspiracy theorists on social media, this seems like a smack in the face and proof that we're trying to kill their babies because they don't understand the way science is conducted or how scientific evidence and literature is analyzed. And yet, I guess what I would point out is that many physicians are guilty of the exact same fallacy here. So this was a randomized controlled trial where patients were appropriately randomized to receive either what they called intensive ultrasound or regular ultrasound, and there was a difference found in the two outcomes. But if you listen to our last episode about Bayes' theorem, you might understand that theorem is one of the many reasons why we don't believe the result, and many others like it. And I like studies like this because our listening audience doesn't believe this result, yet here's a randomized controlled trial that says it's real. And so you have to learn how to analyze literature like this in a responsible way to not just dismiss the results of the trial, but to contextualize them and to understand why they found that and what it means and what we should do about it. So some points for your journal club, the authors did multiple comparisons, but they didn't do a multiple comparator analysis to adjust for that. That's an issue. The average birth weight in the intense group was not statistically significantly different from the average birth weight in the control group. And because of this, they admitted that a very small number of outlying pregnancies changed the result. And that's the sort of result that you would expect to see due to random chance in a subset that's not been adequately powered, and perhaps just a very small handful of misallocated pregnancies makes that statistical variation appear.
SPEAKER_01So in other words, they they could have just happened to have a couple of really small babies for some other reason that happened to be in the intervention group, like two or three different patients. And if they had been allocated differently, the effect could have even gone the other way, maybe and made it look like intense Dopplering prevents growth restriction.
SPEAKER_02Yeah. Yeah, it excites the cells and they grow faster. Yeah. Yeah. And this is why we do replication and why we treat preliminary findings as exactly that, as preliminary. Now, the way science works is we do replication. And this study was part of a larger trial called the RAIN study that had 12-year follow-up. They found no difference in the growth or outcomes of the two groups of children in this study when they looked at them. And more importantly, we had many more trials to follow this study from 30 years ago, including studies in Norway, in France, and in the Netherlands, where we've tracked tens of thousands of uncomplicated pregnancies and found no differences in intense versus less intense ultrasound groups for any metric, including growth metrics. Now, it's another criticism that using ultrasound too frequently might lead to extra interventions, like inductions of labor, and that's probably what happened in the original trial. The birth weights might have been slightly lower in the subset that received ultrasounds because some of the ultrasounds might have found pregnancies that had abnormalities like oligohydramnials at term that indicated earlier delivery. And we're talking about a, I think it was 25 gram difference, right? It doesn't take much to skew that way. But systemic reviews performed since then agree that ultrasound is safe, and you know whether it's needed and what unintended consequences might come from doing it in terms of the labeling effect that we discussed before and how that might influence earlier inductions or cesarean deliveries, that's a different conversation. But to claim that it's unsafe is simply unscientific. Now, I would point out, though, that physicians who would criticize these TikTokers and scoff at their silliness and how they interpret this for claiming that this study shows that ultrasound causes fetal growth restriction. Well, we should all be leery of making similar claims based upon subset findings or novel findings from clinical trials that haven't been replicated or things like that, where we assume causation from association. And this happens all the time at nearly every meeting I attend, where folks discuss novel findings and assume causation where none has been established, or take as a fact something that's only been demonstrated in one study or in some subset analysis. So just because you like the outcome doesn't mean you get to support it. Check your own bias, is my point here. It's just obvious in other people who claim things that you're uncomfortable with, but we do the same thing.
SPEAKER_01Yeah, and it I know it's just speculation to think about pathophysiology, but there doesn't really seem to be any biologic plausibility that would lead to that kind of outcome where there's only a few outliers and not like that the average birth weight of the whole group would be lower, with if you're gonna claim that it causes growth restriction, but then the average weight isn't lower. It's just not biologically plausible. But yeah, overall, this seems like probably some kind of hype that's driven by algorithms for people that are interested in like you were saying, the alternate health movement, maybe favoring the free birth type influencers. And remember, we've brought up before that that those people too are making money off of people's clicks and subscriptions and likes and comments and all that kind of stuff.
SPEAKER_02Yeah, click the link below for 20% off. The pediatricians are always frustrated because the folks selling detoxes and anti-vaccine sentiments and whatever, they claim that pediatricians make money by giving vaccines, which they don't, but they all make money by selling some detox or some cures.
Recommendations And Closing
SPEAKER_02Okay. Well, we're probably over time. So remember doctorsandlitigation.com is the podcast that Antonio mentioned. So please check that out and give them a subscription and listen to. And we'll be back in a couple of weeks to talk about PMOS.
SPEAKER_00Oh, I can't wait. 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.