MBC-Midwifery Committee Meeting #3,

 

 

 

 

 

 

Held in

Sacramento,

Medical

Board

Office

June 6, 1994 / Tape 3, side A


Verbatim transcription of audio tapes recording the preceding of the Midwifery Implementation Committee -- Dr. Joas and Stewart Hsieh, Co-Chairman

Members MBC present: -- Dr. Joas, MD; Stewart Hsieh, JD; Dr. Schumacher, MD

MBC staff present: Doug Laue, Anita Scuri, JD, Linda Whitney, Tony Arjil, Rick

California Legislators: Senator Lucy Killea

Lobbyists: Joan Hall, CMA; Judge Gordon Cologne, JD and Mr. Barnaby -- malpractice carriers

Consumers: Todd Gastaldo,DC; Kathy McChesney, Kathy Forcas, Citizens for the Legalization of Midwifery (C.A.L.M.)

Other professional witnesses: Steve Keller, JD; Shelly Scalla, MD (obstetrician from Oakland)

Midwives (partial list) : Tonya Brooks, CPM; Shannon Leahy, Maggie Bennett, CPM; Maria Iorillo, CPM; Faith Gibson, CPM, Harriet Palmer, CNM


===================Tape 3, side A only===========

Shannon Leahy: (speaking to Mr. Barnaby): and you said you won’t cover them {doctors} for home birth, ... are you going to drop them if they backup a midwife who does a home birth and that person has been transferred into the hospital, are they covered for insurance?

Mr. Barnaby: I can’t answer tell you the decision on that because I know my company, the Doctors’ Company, I don’t own it, its just a company that I represent but I don't think they have made any firm decision on whether to insure a physician on working with lay midwives, I think they see that as a decision they are ultimately going to have to come to grips with but I can’t tell you where they are going to go with that , I don’t sit on the board, I’m their registered representative here and I carry out there policies.

Faith G: Since the April meeting has there been any change of policy whatsoever?

Judge C: Not that I know of, absolutely not, since the first of the year, since the adoption of the law there has been no change of policy and I would doubt that they ever indent to be intend to be retroactive, I mean try to be mean to doctors by refusing insurance simply because they use lay midwives.

Mr. Barnaby: I think that Linda Whitney’s point was well taken -- if there is a demand for coverage it will probably come into existence. There may be a cost associated with it but if there is a demand and people want out there want to buy that coverage for a reasonable rate, then it will probably come into existence.

Judge C: I would think so. It give them an opportunity to have better coverage.

Mr. Barnaby: But if the demand is there, usually they will tailor a product to fit it.

Shannon Leahy: ....When you said the second thing that you wanted was a signed agreement by the parents which would be a signed affidavit that was submitted to the medical board as a parent, that means that I as a parent have to sit down and put down my name and social security number or whatever and send this data into the medical board, so where is my confidentiality? This means that every parent that consider this has to send in to a government agency an affidavit that says that ‘yes, I know that this is risky, yes, I know that this is not covered by insurance’ and think that this is a violation of peoples’ rights of privacy. And then the very last thing that I want to throw out is that a lot of the cautions that we are talking about here in supervision and written things the doctors are going to sign, the agreement, these are covered very well in many states by protocol. Why can’t we put into the regulations, regulations that say written protocols are annually or every 6 months or bi-annually or whatever it is, signed protocols by a physician that say ‘OK. you can do this, you can do this’, whatever it is , why do we have to have ____?______, can’t we just all agree that we have to have protocols? ___________?_____________

Cross talk

Shannon L: I think it would be harder than having a doctor sign something and sending it in to them. Its easier to get a doctor to sign something your going to keep.

Dr. Joas: I think that when Rick comes up with some information on how people do this in other states that we are going to have a better understanding and appreciation of how people do that and perhaps we can incorporate some of these ideas from that standpoint, from that data.

Tonya Brooks: I have an idea that might work on the ratio, Joan was concern on how they would verify it and also on the written agreement. If midwives were to be licensed and put together a midwifery group, why couldn’t they just like a medical group does, they submit the name of their team to the medical board? For example, if I’m going to have a midwifery group which would be like _____?_____, or whoever, why could we put together a midwifery group which we would submit to the board with ‘this would be the supervising physicians and this would our OB and pediatric backup backup, blah, blah, blah, why wouldn’d that satisfy everyone’s requirement because when our birth center got its medical {governing} board and submitted it license to the Medical Board and our doctors simply sent in the names addresses and ___?___that kind of thing to the medical board, why would something like that which is simple, why wouldn’t that be ----- of all of these regulations, then we don’t have to have the concern about whether our midwives are going to have trouble getting a doctor to sign protocols which we found quite easy but others are going to have trouble which we would find very difficult in southern California which is for doctors to sign a contractual agreement as our supervising physician. so why wouldn’t it work very well the way the way the medical board already does it in the medical group?

Dr. Joas: I’m not sure it wouldn’t..

Tony Arjil: That is for a ficticious name

Tonya B: Right, why couldn’t we do something like that?

Mr. Barnaby: You may be on to something. In this case we would have a document that provided which provided a start time and presumably a term of this agreement. It would be between a midwife group and some licensed medical doctors and a ratio of midwives to medical doctors would not exceed the 4 to 1 required in the law and if the doctors were signatory to this agreement, I don’t see a problem with that, does anybody else see a problem with that?

Steve Keller, JD: Just about everybody around here sees a problem with that. That’s exactly what we’re saying -- not to have, Mr. Lane, ----cross talk-----

Steve K: If you take a look for example at the nurse practice act, now that's an interesting model, because there they have standard procedures and protocols which regulate the practice when they operate in their expanded function. Now that is something that I have lectured midwives for 15 years on the desirability of having written protocols, there are lots of wonderful things that come from that, where the doctor and the midwife get together and they work out this and I lectured for that in detail. that provides for _____?____. It Also provides specifically ‘that nothing in this section shall be construed to require approval of standardized procedures by the licensing agency". That’s what people object to, the idea that they would involve you in telling them how to practice midwifery.

Mr. Laue: We’d have to because we have to........

Todd G: No, no, you don’t have to

Mr. Laue: .......enforce the 4 to one ratio, we can’t ........you have to tell my how we can enforce that provision of the law absent any documentory evidence?

Steve K: You enforce that precisely the way you do the rest of the act. In the act it defines unprofessional concoct, it defines gross negligence, there are 15 things defined as violations of the act for example having to do with drugs, OK, now you do not require any midwives to come in and take urine tests and deposit those with the Board. Similarly, you have absolutely no authority and no business requiring them to deposit something with the Board under penalty perjury or some kind of affidavit which defines their 4-1 doctor ratio. That’s certainly a lot less of a thing that the concern the Board would have not to have practitioners using drugs or any of the other things in the section that provides that. This is precisely the kind of thing that would be viewed by these people as an invitation for harassment, an invitation for talking with people like the insurance companies and giving them an opportunity to cancel insurance. And something that is absolutely not required by the statute. If you find evidence of violation like you would for drugs or fraud or any of the other things then you have a cause of action to revoke their licenses, you got to the district attorney, but it shouldn’t be handled any differently,

Dr. Joas: How would you solve the problem, what would you do, if you were in my position?

Steve K: Specifically with regard to written agreement?

Dr. Joas: OK, let talk about written agreements.

Steve K: I think they are an absolutely terrific idea, to have written protocols to define but I don’t think you have any business in writing them and I don’t think its subject to your approval. What I would think is that a written contract would be subject to they people who are involved in the thing, the doctors and the midwives to work that out.

Dr. Joas: So you don’t have a problem with the content.

Steve K: I don't’ have a bit of problem with that. What I would do in the long run is I would recommend the Senator go back and adopt some language that is like in the nurse practice act, that does authorized certain formal as opposed to content things, like for instance, it says there’s got to be an agreement in writing, its got to be signed by the doctor, the nurse and the administrator. There are certain formal things. But I wouldn’t recommend that under this statute, I wouldn’t do that. I don’t think that the legislature ever intended that, they certainly knew about the nurse act and if they had wanted you to adopt this kind of thing, they would have told you to do it.

Dr. Joas: So how would you deal with supervision?

Steve K: I wouldn’t touch it, I wouldn’t touch it, I don’t think your authorized to do it, I think your invading the midwifery decision, you are making decision with regard to the standard of care and that is up to the doctors and the midwives.

Dr. Joas: How do I justify or come to grips with my conscious as a Consumer Affairs protector sitting up here on the Medical Board, appointed by the governor and accepting the responsibility for accountability for those particular people under this particular green book that tells me that I have that responsibility, how do I live with myself then if something goes wrong?

Steve K: I’d love to answer that but a lot of people have their hand up but I’d be glad to answer that after if you’d like.

Dr. Joas: Your making some good sense to me here so keep informing

Steve K: Well, what I’d would do is I would look at the enforcement provisions of the statute. In the first place, the legislature adopted criminal, misdemeanor criminal remedies for violation of this statute. Secondly it adopted regulatory powers which it awarded to your Board for unprofessional conduct, for gross negligence and for a whole bunch of things. The general way is that you would have a strong enforcement arm that when you get complaints of violation of the act, just as the nursing board does, just as the LVN board does, just as your own board does, .... investigation and if you find evidence of criminal misconduct, you report it to the important people, if you find violation of disciplinary ......, you take disciplinary action. That’s how I’d do it.

Anita S: I was trying to clarify about the {untranscribable}

Dr. Joas: that how I see it, nursing and medicine I would call collaborative, that is the terminology I would use, because they run into each other every day, 2 or 3 times a day somebody can say ‘oh by the way’. But in this particular situation, there is a different relationship because the midwives are out in the field and are reporting and the .....for reporting are not as clear as it is and so I guess the level of trust has to be even greater, OK? and if .. I personally can’t bring myself up to that level of trust because of the fact if you’ve ever been sued and you can’t not be sued if you ‘** been in practice as long as I have you have at least one lawsuit under your belt and I can assure you that its an experience you will never forget. I don’t have to tell you that but for me that’s a big stretch, to say ‘yea, I accept that on faith’.

Steve K: I can understand your feelings on that, I can understand that.

Kathy McChesney: I would like to comment that I do accept that concept on faith, I don’t’ know if you remember a letter that I gave to you about a month ago about I have a supervisor and I work in different city and I don’t talk to him on a daily basis, occasionally I don’t talk to him on a monthly basis. But we have a trust where if I need him, I go to him. And I’d like to see some similar between the midwives and their physician. That they can have the quote "supervisor" but it doesn’t have to be a tight agreement, it can be very flexible.

Susan ??: {unable to transcribe, long}

Dr. Joas: I hear what your saying, I accept what your saying, even in medicine today, the concept of certification and re-certification, the fact that I’m board certified today and got my boards 25 years ago does not necessarily say that I’m going to continue to be board certified because somebody is going to come along and say "that’s it buddy, you go back to school and get yourself brushed up to snuff so you can continue to practice, put your self out as capable of practicing". And then I have to sit and argue that from the stand point of I haven’t even looked at that for the last 25 years, its going to take me forever, I give up my {Medical} Board position I do these other things so I can bring myself back up to speed.

So that’s another part of the issue and the other part of the issue is, to me, is accountability, everyone has to be accountable to somebody. And being accountable to the patient is fantastic and it would be great if you could say ‘I think I did the best possible job I could your Honor’ -- well, how come I’m behind bars? And that’s the problem in a litigious society when the United States has 75% of the lawyers. And that’s partly what I’m looking at and I don’t feel that way, I don’t practice that way, I don’t practice with an attorney siting on my shoulder and never have. The people who know me well know that I’m very aggressive and take good care of my patients. As a matter of fact the little nickname that I have is "Overdose Joas", OK?, if one drug is good twice as much has got to be better and my results are fantastic. And I’ve never been brought up on charges.

General, laughter..and good-natured cross talk

Maggie B. Again you’ve hit on a real, almost tangible, stumbling block as far as communication. It is very hard for those of us who are midwives to even relate to what your saying. I have to tell you honestly, I have practiced midwifery for 18 years. I don’t know what happens to you if you overdose to the determent of the patient but I know what will happen to me if I do it wrong and I can’t afford these ..... and I may well land in jail and yet because women have wanted to have my services, I have practiced for nearly 20 years. I want desperately to have a license. I have a profession that I have a license for and I know what that feels like and I’d like to have a license for this one too. And I would desperately like to hear, to know somehow, that the powers that be are hearing how it is. I keep hearing gentle voices, well meaning voices saying "just wear these hiking boots and you’ll make it over the mountain". And I keep trying to tell you -- the hiking boots don’t fit, they don’t work, no matter how hard I try to keep them on my feet I will stumble and fall.

Todd G: She should have been grandmothered in as a midwife, she should have been grandmother in as a licensed midwife, she should be one of the authorities...

Mr. Laue: I would ask you to also walk a mile in our shoes, put your self in the role of an investigator, investing a problem. And the investigator goes to the licensed midwife and the licensed midwife says "I have a good relationship with this doctor who is my supervisor under the law and I don’t think he’s got or she’s got more than four to one, I don’t know, I guess under the law I’m not charged with that responsibility". And the investigator goes to the doctor and he says "Yea, I did that with her at one time but I don’t’ have that relationship anymore, I haven’t talked to her in a month, ah, as far as I’m concerned we don’t really have a supervisory relationship’. Who do you presume is telling the truth? And where do you go with that investigation and how to you tell who is culpable and who is not culpable under the law?

Maggie B: I want to know, first of all, in a bad outcome, a fetal demise, will you be looking to see whether I was supervised and how many midwives can my doctor supervise or will you be looking to see ‘did I know that baby was breech’, or did I know how to catch a breech baby, did I do all that was possible to save that baby’s life, believe me, if push comes to shove, I think those are the things you are going to want to find out about.,

Mr. Laue: We need to know all if it, we need to know are you practicing legally, that means are you licensed, are you being supervised as the law calls for, is the supervisor have up to the maximum ratio, we cover all of those things. We also need to look at the quality of care angle in the investigation but on those basic fundamental things I want you to tell me how to short that out?

Maggie B: I think one thing you are going to do is your going to clean out my files and your going to look in the file and your going to see whether or not there has been disclosure you’re going to see the name that the mother (cross-talk} the name of the doctor

Cross talk

Mr. Laue: Oh no, these are fundamental things that the law asks that are investigated

Maggie B: the truth is that you are going to look to see if I screwed up as a midwife.

Mr. Laue: Well there is a provision that says all complication shall be referred to a physician immediately, your going to want to document that, when did you know that here was a problem and what did you do about it.

Joan H: You have accountably and the physician has accountability

Mr. Laue: yea, right....

Maggie B: So you’re going to want to look, you are going to grab my records fast as a cat can wink an eye and see did I ever record that the baby was breech, ah, did I report it to a physician, did I refer the women to a physician, did she refuse to go to a physician. I think we have to be very careful also that we don’t put ourselves in position where we’re requiring doctors to do something that they won’t do. We can’t do it. I can’t go and grab this guy and say "You have to supervise me and you got to sign this paper". And I also can’t say "you have to go to the doctor", especially me.

Cross talk

Mr. Laue: It becomes a part of the law that is not enforceable.

Maggie B: I can’t walk in your shoes I have been too busy running for too long, I’ve been too busy being a felon waiting to get caught...for me to imagine ...

Maria Iorillo: {hard to transcribe} I have a question about midwives regarding supervision. It seems really clear to me that they....... found that advantage of a written agreement was to get the name of the doctor and ...... that’s exactly what they said and its clear that the medical board wants a written agreement

Dr. Joas: I don’t think its that clear yet

Maria I: OK or that they want some .... but it would be an easy way to see that there is only four per doctor and each midwife did have supervision. Now my question is how does the insurance company get that information? Can you do it so that you can see that four to one ratio, see that I have supervision, but how does the insurance company get that information?

Judge C: We don’t have to have that information, we don’t want it.

Cross talk {unable to transcribe} : its a public document.

Maria I: So can we do something about that, can we make it so that the insurance company can’t have access to that therefore

Even if the doctor wanted to supervise me she couldn’t because her insurance is canceled. She’s .....?....., she can’t do it. So what if we protected her, protected her name by not allowing it to get to the insurance company?

Judge C: Let me tell you, I would recommend to Senator Killea that she carry a bill to make it illegal to cancel a policy simply because a doctor was using a lay midwife. We’d have no objection to such a policy, such a piece of the law. We do want to be able to cancel , or not to cancel the policy but to include as an exclusion home deliveries because that a different fee we charge for that than hospital deliveries. We ought to have a right to set a different premium or exclude it. If the doctors only wants hospital privileges by the lay midwife, if that’s all he wants that’s a different premium. I don’t know how this rumor got started -- I didn’t hear it -- but if they said that

Crosstalk: You said it, that’s how -- general laughter

Senator Killea: What you need to know here is Judge Cologne is a very honorable person, he’s very persistent, he’s pushing his own client on this but he’s not, he doesn’t tell lies. I do appreciate this.

Maggie: I want to say that I’m pretty sure it was the other insurance agent...{unable to hear last few words..}...

Dr. Scalla: I don’t know that it important who said it because I think you said today that you would not give insurance to a physician who wants to backup a midwife in a homebirth. And all of these ...

Judge C: No, I said we would not include coverage for homebirth but if he or she was doing hospital deliveries, we would cover him, we would be eager to get is business.

Dr. Scalla continues: Exactly, but I think the issue is that these licensed midwives, or soon-to-be licensed midwives are all doing home or birth center births and do not have hospital privileges so for you to always make this distinction....

Judge C: It only in our policy, if you can get insurance for your own policy and do not need supervision, more power to you.

Mr. Barnaby: I even think that birth center situation is treated differently, currently, where there is a nurse midwife involved, I think that the real point where most where most liability carriers do not want to cover is homebirth. But if its a birth center that is equipped and certain kinds of precautions are able to occur, I think that’s treated differently, I could b e wrong about that...

Judge C: Absolutely, absolutely

Mr. Barnaby continues: I think it treated differently, I think the real concern is home births because they don’t know the level of sanitation, and there are all kinds of, you know, unknowns out there and in the insurance business, unknowns mean higher premiums. What insurance deal with is the predictable.

Judge C: I can tell you that I have checked with Southern California Physicians Insurance Exchange and they do provide coverage for home birthing centers. Automatically they provided it for acute care hospitals but on home birthing, I mean, on birthing centers they require an examination to see if there facilities are up to standards. If they are they cover them. They have not done that on home deliveries, they have just not had enough requests for that and in their experience its not worth getting into that business.

Dr. Scalla: I think its very true what you said ‘its not worth it’ and I think ------ for the physician as well its not worth it.

Judge C: Let me tell you if you have 200 lay midwives sign up and want insurance, you going to find one of the companies out there is going to want to get into the business. You say you might have 200, you might have 25, I don’t know where the drawing line is but if there is 200 people out there, somebody is going to give it to them. I’m not going to tell you what the price is going to be but I will guarantee that somebody will want to sell them insurance and don’t think we re going to eliminate an obstetrician simply because he wants to use a lay midwife, I think that would be a clear case of discrimination which might be a anti-trust violation and I’m not going to suggest that any of my clients would want to get involved in that.

Dr. Scalla: Could I ask a question on that?

Todd G: I think there is a solution to that, the last item on Mr. Laue’s time line was clean-up legislation and Dr. Joas suggested that I wait till Senator Killea came here to broach the subject. And actually there was a good preface to the subject when Judge Cologne said he didn’t know why this came under the medical board and why the lay midwives, .... the professional midwives were put under the medical board. The fact of the matter is, according to Senator Killea’s bill as it was amended in the Senator on April 15th 1993, the bill would require the state department of health services to issue a license but the initial legislative wisdom was to put it under health services. And then Joan Hall said after that, she kind of indicated and I think correctly that it wasn’t really legislative wisdom that changed it from a consultative relationship to a supervisoiral relationship. She said that it was the CMA, basically.

Senator Killea: ACOG and the California Medical Association. Yes, that was the only way we could ...

Todd G continues: OK, but what Judge Cologne termed ‘legislative wisdom’ was actually the CMA, we are finding out, but I’m saying

Judge C: untranscribable right Lucy...

Todd G continues: And I’m saying that we could easily go back to the legislation using Mr. Laue time line and introduce what he called clean up legislation in other wards, clean out that which was put in by the CMA, expressly, according to Vivian Dickerson of the CAM and ACOG ‘so as not to issue an invitation to home birth’. In other words according to at least one CAM-ACOG member, who is a professor of obstetrics at UCLA, Dr. Vivian Dickerson, the CMA’s position, she said, held out for physician supervision instead of a more collegial relationship, it was collegial not consultative, so as not to issue an invitation to home birth and I say that is counter productive and I think it ought o be clean out with clean up legislation. And you said you might support it Doctor Joas.

Senator Killea: The one problem is, if I may, is clean up legislative also has to go through the whole legislative process. And the fact that this took so long to do and had so many amendments and it finally got out was simply because we were able to remove the CMA’s active opposition to it, otherwise it was never ....{untranscrible} the legislative process. So it think that’s reality, we did not have the votes without making this compromise. This is what we had to come up with.

Todd G: At the time this bill was going through the senate, Senator Killea, neither the public nor the legislature probably , ah, the CM wasn’t aware yet either, that the British House of Common Health Committee report which they spend two years trying to figure out if the ‘hospitals are safer’ propaganda was true, they found no evidence to support it. Now that that’s out, and it pretty much in the bag -- there is no evidence to support ‘hospital are safest’ propaganda, which incidentally, is used by the Depart of Health services, I’ve talked to Eugenia Shaw, MD, who is chief of the maternal child health branch...

Senator Killea: OK, I think for purposes of today though, perhaps we don’t take time to ...?.. this, but I’d be happy to talk you about follow on that. Thank you very much.

Kathy Forcas: And I represent the consumers who go to lay midwives. I just wondered, is there a way to take that supervisory clause and define it such a way that the doctors don’t have liability, that there insurance representative has trouble with, in other words, if it said consult and not supervise there would be absolutely no problem with insurance because the doctors wouldn’t be liable. Can the supervisory word be in there but we define it in such a way that it takes the liability off the doctor?

Dr. Joas: I’m not sure that we can define it any more clearly than its defined without ....?..

Judge C: If you went back and said that the supervisorial relationship will constitute no liability except for advise for given to the lay midwife which is improper it would solve an awful lot of problems but the trial lawyers wouldn’t let you get it through.

Tonya B: So its the trial lawyer, the insurance companies and the AMA?

Male Voice: and the Medical Board.

Judge C: You got it.

General laughter

Dr. Joas: Yes mam?

Harriet Palmer: I have two points. I’m Harriet Palmer and I’m a nurse midwife and I’ve had a home birth practice for about 15 years. To the gentlemen with the insurance. The American College of Nurse Midwives had an extremely rocky road for trying to get insurance, malpractice insurance for those of us who do home birth and there are far more than 200 of us over the country who are willing to go with something that might be reasonable. Currently I’m hearing somewhere between $5,000 and $60, 000 per year and that really is not a reasonable amount for those of us who only do home birth.

The other thing is that those of is who do home birth I think practice pretty much as those who do births in birth centers, we have the some emergency equipment, the same kinds of things are available at the home. The only difference might be the distance to the hospital but we do practice with physician who are agreeable to see women should they need to go in and hopefully {last 3-4 words untranscribable ....}

Dr. Joas: Thank you. Joan

Joan H: The CMA gets to speak once again. As Senator Killea know we worked with you for months, hundreds of hours were spend on this legislation. And with the full knowledge that homebirth would be occurring. And I think one of the things that we’ve heard quite a bit lately, which is why I’m very glad that both Mr. Cologne and Barnaby are with us today so that some of the angst will be squashed a little bit with respect to insurers actually pulling insurance from physicians. The thing we’ve heard a lot of is that automatically that if a physician has any kind of relationship with a license midwife that their insurance coverage is going to be pulled and that in fact, is not the case. And that’s been restated. If that was the case, there’d be no purpose to this bill -- physicians would not be getting into relationships with licensed midwives. We certainly entered into this bill in good faith and as Senator knows it was not real easy to turn the physicians around on this particular issue.

Senator Killea: You didn’t turned them all around either!

Joan H: No, we did not Lucy and I still get a lot of calls! And we want to continue to work obviously in this kind of environment because the whole purpose of the legislation is that we do have an opportunity for consumers this kind of services to have this particular kind of choice.

I’m not even going to get into your concerns regarding the CMA. But we want to continue to work with you on this and I think that one of the things I’m certainly going to request my organization to do is take a look at this particular form that Rick handed out to us and se if maybe that is a workable, some variation of this form might be some kind of a workable way to identify supervisory relationship where maybe physicians at some point in their licensure process can verify that yes, indeed hey do work with this particular midwife. You as a regulator have the responsibility to determine whether or not the 4:1 ratio is met that is in the bill. This may be a mechanism that we might be able to work on.

Maria I: {hard to hear} Can this information be kept confidential?

Dr. Joas: One of the ideas that I had before the insurance people were here. First of all let me say that what I’m hearing the majority of the written agreement stuff if comes from the insurance people, OK? I don’t think its comes from me or from the medical board, per se.

The concept that I had was that the midwife and the client sign an agreement and on that particular agreement, they identify the backup physician OK, only identify him or her OK. so that there is a document that exists so that there is a responsible party, so that there is oversight, etc., etc., etc., ...

That to me would be a step back from that big leap of faith that I can’t take but never the less is available and possibly workable and possibly we might even get the insurance company to buy into something like that maybe even the medical board would by into something that. I mean, that’s way off the wall...

Tosi M: Is that something that stays in the chart?

Dr. Joas: It says in the chart.. It’s a confidential agreement identifying al the parties that are involved, signed by the family, the client and the midwife, identifying the physician, kept in the midwife’s file available to the Medical Board on call, so that’s there’s oversight. Something around that .....That seems to be one of my

Faith G: Some of us do that already.

Shannon L: Would that ---the physician?

Dr. Joas: It would identify the physician and

Mr. Barnaby: Would the physician know about it?

Dr. Joas: yes

Judge C: How?

Dr. Joas: I don’t know yet, I didn’t make that step but maybe there would be a copy of that in his file.

Shannon L: The reason why I ask is what if Dr. Jones is out of town...

Dr. Joas: Wait a minute, if I’m on call, and I say, ‘yea, I’ take the call for the week end’, your name goes on the call schedule and your the identified individual for that particular call for that particular weekend, for your office and at the hospital and for all the responsibilities that you accepted, so help me Hippocratic, OK? that’s the way I view it anyhow and always have. I mean if I take the call, then I’m in the barrel. .

Woman’s voice -- untranscrible question

Dr. Joas: I would think it would be applicable just as well although I don’t know the HMO stuff, I was going to say earlier that this who discussion may be mote, in 2 to 5 years because we’re not going to have any control over who goes where anyhow, its going to be somebody master planning, saying "OK, Mrs. Smith you go over here and Mr. Jones you go over there " and so forth.

Shannon L: My only other reason for asking is like Tosi said earlier, what if the HMO is 45 minutes away? She ended up taking her to the closer hospital..

Dr. Joas: Yes, but that was her comfort, she was uncomfortable with that. That was a ......?.... statement, I liked that because it also expressed the discomfort of other physicians who have been in supervisorial roles with midwives saying that they were uncomfortable with certain midwives in certain situations at certain times.

Judge C: What you suggested has some merit. And I’d certainly be willing to take it back to my people and see if they could agree with that. It wouldn’t have to be an agreement but that the medical history that the lay midwives prepares would be signed by the patient and signed by the doctor.

Cross talk -- objects to wording of proposal

Judge C: No, no you said the two of them. I’m; saying if you included a signature by the doctor, not that he’s agreed to anything, but that he’s the supervisor, not the term of any supervisorial relationship just that he knows he’s the supervisor. And that’s in the medical chart, we’ve got confidentiality which you were concerned about but we’ve got notice to the doctor that he’s assuming a relationship. And I’d be happy to carry that back. You want the patient to be aware of it, you should have the doctor be aware of it as well the lay midwife. Now if that’s the vehicle, I think we getting close.

Dr. Joas: We moved a half an inch, so I think we’re getting closer. You know’, I’m thinking about this over a 20 foot putt, you know, I miss the putt.

Judge C: Well we want to see this think work, you did a lot of work to get this thing through and we want to see it work but we also want to protect the doctors.

Dr. Joas: And I appreciate it and I think that you appreciate that I’m trying as hard as I can to make the think work too, despite my scientific reservations.

===========================end of tape 3 =======================
end of recording for MidwiferyCommitte meeting number # 3


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