28. The Herzl Family Practice Maternity Group Is Born
It was good to be back home, fresh from the Oxford experience, and sure that we could replicate a similar birth model in Montreal. But the teaching environment was not ideal. Our Herzl graduates, like the older members of the department, were providing office-based care for the neighbourhood and nearby suburbs, but this was a limited form of family practice. Full-spectrum care was the right thing to do. I was also worried that if we continued to produce a family doctor who did not practise full-spectrum care, and who acted mainly as a conduit or feeder for specialist care, the Quebec government wouldn’t continue to fund us.
Emboldened by the Oxford experience, I decided to begin the maternity care process at Herzl by starting to attend births myself. Initially, I made an arrangement with our obstetrical consultant, Emily Hamilton, to act as her house officer or assistant when she was on duty and I was available. As chief of the department I had the flexibility to do this. So began a personal refresher tutorial from Emily. It lasted six months, at which point, like a mother bird, she kicked me out of the nest. So I attended births and soon hired two and then three other family doctors who had practised full-spectrum family practice, including birth in rural settings. We also worked with Sally Jorgensen, another supportive obstetrician.
Our family practice birthing group of Cheryl Levitt, François Boucher, Michael Malus, and I were a team. Many in the hospital thought we were nuts but harmless. The chief of obstetrics, in a bizarre twist, thought our maternity work was a kind of feather in his cap. But for the most part the McGill medical students were not interested. Simple office practice, with lots of referrals to specialists, was their plan.
We loved our work, but the four of us and the other Herzl teaching staff were unhappy. Our mostly McGill-educated trainees did not want to learn what we wanted to teach. We recognized early that a happy faculty was the most important factor in a successful program. Without talking to the overall McGill faculty, we began to quietly discriminate against our own McGill graduates when they applied to our family practice program. To fill our program, I crossed Canada to interview potential family practice residents in places where full-spectrum family practice, including births, was the norm. I interviewed medical students from Halifax to Calgary to Vancouver. We enticed trainees from other provinces to join us and, in the most unlikely city setting, prepared them for full, often rural, family practice—including, of course, attending births. I got a kick out of it when one of our residents, the son of the chief of pediatrics at Children’s in Montreal, decided to become a rural family doctor.
We four started small but soon developed a reputation for respectful and flexible woman-centred care. The floodgates opened. This influx was in part because of the negative experiences that women had with the conventional obstetrical establishment. Some women had been rejected—in fact, fired—by obstetricians because their requests were thought to be bizarre or unreasonable, or because they questioned the routines in maternity care. For example, some women were fired from their usual obstetrical practice because they pushed back against routine induction of labour based on a presumed due date—requesting instead that induction be reserved for demonstrated need—or because they requested that routine episiotomy not be used.
Another reason they were being fired from an obstetrician’s practice was because they dared to inquire about the particular obstetrician’s rates of various interventions, or their approach to pregnancy, labour and birth. Typically, they received the answer that the practitioner would do what was necessary and the woman should leave such issues to the practitioner. “Don’t worry your pretty little head. Just leave it to me” was an extreme example—leading to the woman’s decision to exit the practice immediately. So they came to us.
Receiving this population at Herzl was an opportunity to build our maternity practice and demonstrate our flexibility, to show that we were different from the dominant model of maternity care in Montreal. At first we did not realize what was happening—that the women who entered our maternity practice did so specifically to receive what they thought, based on the maternity “grapevine,” we would provide. They were very different from women who had been in our family practice for some time and who trusted us implicitly. When women already in our practice became pregnant, it was usual for them to just continue with the already established relationship.
For the new arrivals, however, trust could be difficult to establish. For many, we were often considered as merely the best of a bad lot. Some women came to us via organizations such as the Centre for Alternative Birth or Birth, Renaissance (it works better in French: Naissance, Renaissance).
To demonstrate our commitment to addressing their needs and to show that we all operated with a similar non-interventionist approach, we began meet-the-doctor night, when the four of us would meet every three months with the couples approaching their births. We answered questions and ran a kind of brief evening childbirth preparation session. The parents appreciated that whichever one of us actually attended the birth shared the same philosophy and approach as the others, and that we used technology only if it was really needed. This model eventually spread across the country in many places where family practice maternity services developed and flourished.
Initially, we used soft call, meaning that we were all on duty for all our own patients’ births, except for some weekends and vacations. Hard call is when you are on duty only when it is your turn. Before we started our meet-the-doctor nights, most patients expected their own doctor to be at the birth. Although this form of continuity seemed the way to go, it was also a prescription for exhaustion and burnout. In later years, or as we aged, it was common to switch to hard call, even for women family doctors, who initially felt a particular imperative to be at the births of all their patients at all costs.
Unfortunately, our trainees generally couldn’t envision the soft call model as a standard for themselves, as they not only saw the exhausted practitioners, but they also worried about integrating maternity care into their future office practice. They thought that this style was incompatible with the structure and demands of a scheduled office practice. Especially as the majority of the new generation of family practitioners were women, the soft call solo model was a big problem for many trainees. They might have said of an excellent family doc: “Isn’t she wonderful? I want her for my birth, but I don’t want this kind of practice for myself. It’s just too demanding.”
I described how I coped with patients who had a long list of requests in an article titled “Contracting for Trust in Family Practice Obstetrics” in Canadian Family Physician.6 This was in the era before what came to be known as birth plans. The article was unique in that it was written in about an hour by dictation, while I was lying on my back in a hospital bed recovering from back surgery. It just poured out, which was very different from my usual article that took many weeks or months to write. It illustrates not only my increasing focus on maternity care but also clearly shows the struggle of providing a different kind of maternity care in a city where the care model was specialist-dominated and authoritarian. This became one of my most commonly used articles. Typically, women came with a long list of requirements for their ideal birth. Patiently going through the list was not enough, as the list was seemingly endless. What was really going on was a testing process in which the woman and her partner, who did not yet know me, were using the list to determine if they could trust me. Trust and issues of control were at the heart of the exercise. Although the article describes occasional struggles over control issues, nevertheless, because of the respectful discussions, the patient generally becomes comfortable. When trust and control were directly addressed, the list disappeared.
When trust could not be easily established, I noticed a particular past history. Persons in authority had taken advantage of the vulnerability of the patient, often going back many years, so it is not surprising that the patient would have difficulty trusting any other authority figures.
The most profound injury to the ability to trust is sexual abuse or other injury based on major power imbalance. In my practice, those who could not trust me almost always were survivors of sexual or other abuse. Although they did not leave the practice, in some cases it took many years until the patient could finally begin a truly trusting relationship.
In current practice, so-called unreasonable or inappropriate requests should lead to a written document in which the patient acknowledges that since she is autonomous, she is entitled to make decisions about her care. But the document also should indicate where the professional feels that she is not providing what she considers safe or appropriate care. The professional can thus continue to provide care that may be outside of what they consider to be ideal, or even what the institution prefers. In the early days of our maternity group, unusual requests or patient behaviour often led to the following comment by our obstetrical colleagues: “Oh, another of your crazy patients. Can’t you control your practice?” Reply: “These patients have always been there. When you kick them out of your office, they come to me. If you would change your behaviour, I would have fewer such patients.”
If you delve into an apparently bizarre request, you will often find that it is a test. Unconsciously, the patient thinks: If I make a truly strange and difficult request, and the doctor agrees, perhaps this authority figure can be trusted after all. In the end, these “failures” can be opportunities to learn about what is beneath apparent difficulties. I acknowledge that large numbers of such requests can be a major drain on a doctor’s energy and personal resources, but they also can be a source of great satisfaction in working through the patient’s reasoning.