A medical advocate?

One of the best investments my wife and I ever made was $1,000 for a midwife for the delivery of our second child. For this we got a stream of advice and a few visits before the delivery and then she was with us throughout the delivery.

The woman in question had been head nurse – perhaps called ‘matron’ but that just makes me think I’m watching a Carry On movie – at an obstetrics ward. The best thing about it was not all the things that people think about with midwives – that they might be a tad ‘alternative’. They’re certainly well informed about a bunch of practical things that the Obstetricians are strangely oblivious to. But that’s not the really good thing.

The point about this woman was that in a massive system, where we’re tired, outnumbered and hopelessly outgunned in expertise, she was our advocate. So when there was a changeover of the official midwife in the ward and the new, one started bossing us around, when I was on the verge of completely losing it with this woman’s robot routine, our own midwife just took over and got done what I wanted without anyone having to be punched out (it would probably have ended up being me).

So I’d like to see this kind of role developed more fully. Whenever one had a substantial medial procedure or problem a ‘medical advocate’ would husband you through the system. You’d pay them to help research the condition, help you research, choose and quiz specialists and so on. Of course it would be quite expensive, but I’m sure I’d be happy to pay for it at least in some circumstances. And there’s plenty of money flying around so there would be at least some market for it. In a way an architect has a role a little like this in building a building – of being the impresario – a person who is at the apex and makes it all happen – and happen well.

I was reminded of this when Tim Watts sent me a link to a post of his about ‘information therapy’ which comes at similar ideas but from a different (informational) angle.

Seidman and Sepucha propose that health providers ought to work with these changes in citizens information consumption and provide tailored information therapy to help patients care for themselves. As the PPI describes it:

For example, a doctor who has just told a patient that she has diabetes could follow-up the visit with an email with links to information about managing diabetes. The patient will be much better equipped to process the information at home with the support of loved ones. Today, that process happens with haphazard web searches without any feedback going back to a physician or a nurse about whether the patient has found reliable information and has begun to master the disease.

Its easy to see how such information therapy could involve connecting patients to online communities of patients with similar conditions, harnessing the new cooperatives identified by Tom Watson MP. The potential of linking information therapy of this kind with electronic patient records (of the kind that Google and Microsoft are now working on) would be enormous.

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David Rubie
David Rubie
13 years ago

Might need a Gruen Tender to sort them out. The midwife/birth aid/dirty hippy we first encountered on recommendation of our doctor encouraged us to save the afterbirth of our first born and consider cooking a bit of it and eating it. Hers was apparently buried under a tree in her backyard (sans a snack sized portion, we assumed), and the tree was apparently vibrant.

Er, no thanks lady.

The ordinary midwives are fabulous though.

Yobbo
Yobbo
13 years ago

What happens though if your midwife is wrong? Do you want a less-trained person directing the actual doctor?

pale_ale
pale_ale
13 years ago

Yobbo. Where does Nicholas say that the advocate / midwife directs the doctor?

Caroline
13 years ago

A good idea Nicholas, but I can see medical advocates getting up the noses of doctors. Advocates would probably need to be assigned to, or appointed by, said doctors in order to secure cooperation.

I once knew a radiologist, (an ‘actual’ doctor egads,) (who rolled his joints up on his business review mag) who said he loved his work because it paid really, really, really well, and he didn’t have to treat anybody, just deliver them up the bad news and then bid them ‘goodbye’. A real charmer. I’ve known people who in blind trust have put their health into the hands of a cast of health care ‘professionals’ working in big hospitals only to be discharged at the other end and told ‘sorry there’s nothing further we can do’. This is usually about the time they decide that maybe some alternative therapy might be worth a shot.

Never ever entrust your health to people who work in large hospitals, without foremostly knowing exactly what they are doing and why, as its alarming how often they don’t. Most, ‘mean’ well, but can neither afford the time, nor seem to have any aptitude to actually care or (roll your eyes) ‘heal’ anybody. What a quaint old fashioned, ‘alternative’ notion that is–health care professional as healer. Heh.

It sounds in your case that a former matron midwife had the strength of determination and personality to sort out an officious sister in charge, but its a sorry state of affairs when it comes down to an individual’s strength of personality, whether professional or patient, as to the chances of them getting the right (ahem) ‘care’ service.

Sinclair Davidson
13 years ago

An alternative is to have a birth plan that you have discussed with the medical staff in advance. This sets out what you want and don’t want etc. These seem to be relatively unknown in Australia – at least few people I’ve spoken to have considered it. (I don’t know if the plan itself adds value, but the process of ‘negotiating’ it in advance may be the key).

Patrick
Patrick
13 years ago

I have to admit that our only child born in Australia involved my basically telling the hospital midwife to f*** off she was so damn rigid and stupid. I told her that, based on the possibly-slightly-relevant evidence of our previous child, we would be done and dusted in two or three hours but she didn’t even want to come back and check for four more hours!

Worked out well because in the end we were most ably assisted (just under two hours after that exchange) by a lovely junior midwife.

But Sinc’s plan, whilst attractive, would require doctors to listen – some do, but many don’t. The doctor at this birth seemed only really interested in anaesthetic, which my wife didn’t want – but nothing could really convince him of that, it seemed.

Sinclair Davidson
13 years ago

Yes, I agree.

Francis Xavier Holden
13 years ago

Sinclair – birth plans are very common. And there are a multitude of templates around.

We had them for both our kids and had discussed them with the birthing unit prior.

Of course they count for nothing if things are going pear shaped. But then who would want to insist that the birth be “drug free” when the woman is shouting “Fuck the plan I am in pain” or “Fuck you men this is hard work” or more seriously when a life is in danger.

Francis Xavier Holden
13 years ago

Mr Jacques Geekster – when I try to post a medium long comment – Troppo won’t accept it. I have to break it up.

I hope it isn’t just a filter for me. [looks over shoulder adjusts tinfoil hat]

i am using Opera

Francis Xavier Holden
13 years ago

nic – in a lot of health care the GP should be the co-ordinator / fixer and I’m sure that if you slung your GP $1,000 you’d get a lot of service.

The problem with hospital stays is not so much the planned ones where you can think it through but the unplanned ones. Going to hospital is a bit like going to court. When you havent been in the dock much you are likely to be disorientated and confused so its best to have a few visits first or someone who knows the system – like a lawyer. Having a lawyer in lot of minor cases isn’t so much about knowledge of the law as the day to day familiarity with the system. Going into court a few times when you don’t have to is good to calm the nerves and you will perform better before the coming big Royal Commision Into Mortgage Lenders say.

Francis Xavier Holden
13 years ago

People over 60 often go to hospital quite a bit (by 60 you will have only used half the health services you will use in your life) so that after a few visits people can take much more control of their hospital stays.

It makes good sense to have a health services “fixer’ a good Gp is best I reckon but anyone who knows the system – a nurse relative, or other health worker friend can be a good broker. But as for an outsider “taking charge” in a hospital it’s not on.

The Worst of Perth
13 years ago

I had the impression that the midwives we encountered had just flown in on broomsticks. Firstly they lie. All that guff about how every decision will be up to the mother to be, as far as pain relief etc is pure cobblers. What they mean is that they will do whatever they think is right no matter what she says. For some unknown reason they also made it clear that the mrs would some sort of criminal if she didn’t breastfeed, despite numerous problems with it. I’m glad you had a good experience, but ours were rude, cold and generally awful.

Sinclair Davidson
Sinclair Davidson
13 years ago

FXH – All (most?) preparations go out the window when the birth go pear-shaped. Both my sons had difficult births and large parts of the birth plan got abandoned early in the peace.

On the issue of drugs etc. there is (was?) a Melbourne hospital with a natural birthing unit. Mrs D and I went to their sessions and seminars and stuff and listened to (what I thought was) some very scary stuff. The midwives there were basically saying that ‘real women’ pushed it out with no drugs etc. and that medical doctors were all men conspiring against women the deny them the chance to experience real womanhood (I’m paraphasing a bit).

The Worst of Perth
13 years ago

No I wasn’t interpreting it that way at all. It’s just in the limited experience I have had hospital and outside midwives is that they are presented as your advocate, but that can be just an illusion. They really have their own agendas and pet theories exactly like the doctors.

Francis Xavier Holden
13 years ago

no message just nothing will post until i break it up

James Farrell
James Farrell
13 years ago

This is an interesting issue, but I’d like to think we could approach it a bit more generally and systematically.

To start with, I think the concept you are after is agent rather than advocate. Advocacy is only one thing agents do; furthermore, there is a certain type of officer in the public administration called an advocate, and his/her advocacy tends to be on behalf of groups with particular needs in common, rather than individuals, whereas it’s the latter you seem to be interested in. Also, the sorts of deficiencies you want to fix fall under the general heading of ‘principal-agent problem’, which is already an established field of investigation.

The question this research addresses is, at the most general level, when does it make sense to employ an agent, and under what circumstances does an agent act as the principal wants her to. Obviously the agent helps to overcome an information asymmetry, which is why we have lawyers, brokers and buyers’ agents for real estate transactions, and why we get architects to negotiate plans through council. But, just as the sellers of credit, shares, real estate, insurance and so on have an incentive to cheat the buyer, so in principle does the agent, who can take advantage of related informational asymmetries, although in other ways.

I can see this is turning into an essay, which I don’t have time to write, Apart from that, of course you know all this. As long as you can see where I’m coming from and where I’m heading…

As an aside, I’m struck again by the way in which attitudes to the public sector are shaped by personal experiences. I’ve raised this with you in the context of schools, but it seems to apply to hospitals too. Both of my children had difficult and extended deliveries. In both cases we dealt with a succession of midwives, but they were without exception absolutely terrific — competent, professional, caring, ready to answer questions — and we never had the impression that they were anything but our agents in dealing with the difficulties of childbirth. You really need to move to Western Sydney, and you can save your money for theatre tickets or World Vision sponsorships.

Sinclair Davidson
Sinclair Davidson
13 years ago

Picking up of James’ point – I’m not sure if there is a real difference between public and private births per se. The staff during the process itself have always been wonderful. I think we overlook the fact that child birth is a very traumatic process and the medical staff do a wonderful job. It’s what happens afterwards that is important and what I think Nick was on about.

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