Diagnosing UHS

In the six months since a Harvard women's advocacy committee first filed a formal grievance against the two gynecologists who practice for University Health Services (UHS), the doctors, the complainants and their many intermediaries have agreed on only one point: Much more is at issue that the initial charge that a doctor performed too many Caesarian sections during a five month period in 1981-2.

Foremost among the questions raised by the Harvard Medical Area's Joint Committee on the Status of Women is whether the complaints UHS periodically receives from patients, especially those about gynecological care, indicate bad practice or simply the "attitudinal" conflicts UHS says are unavoidable when many women must use the same two practitioners.

"The personalities of the doctors has been a problem from year one," says Althea Aschmann, a Harvard employee and one of several numbers of a voluntary oversight council for non-students on the University group health plan. Gynecologic and obstetric medicine has been "a hot issue" for three years, says Aschmann. She recalls a period in 1979 when three pregnant women joined the staff oversight council because they felt they had not received adequate medical advice through normal UHS channels and wanted changed made.

Other council members echoAschmann observations of built-in problems associated with a clinic such as UHS, where all gynecology beyond routine office care is handled by the same two doctors Jerome M. Federschenider and Paul L Winig '62 For example, many familiar with the pair's work describe them as "traditional" in approach, a term used by some to suggest only a reliance on mechanical rather than "natural" childbirth methods and interpreted by others to imply a brusque office manner.

The Joint Committee complaint on Caesarian section charged that Winig had delivered an unnecessarily high percentage of babies using the operation over a five-month period at Harvard-affiliated Brigham and Women's Hospital, Doctors nation wide "have for several years debated the safety and advisability of relying heavily on the Caesarian technique, which involves surgery, and conventional birthing methods.

"I'm convinced that it's not a question of the quality of technical care people are receiving" says Amy Justice '81 a paid, full-time patient advocate for UHS. "There are times when attitude can get in the way of care." "Justice adds, without being specific, but she also says. "You can't fire people for being a little brisk."

But other people have more serious complaints. The Joint Committee wrote in its original guidance in April that part of its intention was to address allegations of "a consistent pattern of inappropriate and rude conduct [physical as well as verbal] on the part of Dr. Winig. "The two-page letter also refers to an undocumented but strong impression" that Winig tended "to pressure patients into surgery before an adequately definitive diagnosis has been made."

Members of the Joint Committee, which includes about 50 women employed in various capacities at the Medical Area, say they have heard many more complaints and some apparently have first had experience with the doctors in question.

The week after the initial grievance on caesarian sections became public in September, committee members say, another women liked a grievance with UHS against Winig, allying maltreatment five years ago when the woman was a Harvard graduate student.

Deputy UHS Director Dr. Sholem Postel calls the second complaint "an overall allegation of poor treatment" and predicted that an in house investigation would take at least several weeks.

Winig says that the second complaint "has not come to [him] yet" Of the Joint Committee's April grievance in made that a review by Brigham and Women's Hospital officials found nothing wrong with his decision on delivery technique and that he is currently re-reviewing" his disputed operations with senior Brigham and Women's doctors.

But the UHS gynecologist adds that he has a sense there are very few complaints" about him from patients "I feel good about that," he says "because the people I treat are the smartest in the city and certainly the most vocal. If there were something wrong they would complain."

Besides the two most recent grievances against him, Winig say, he can recall one other, based on a "personality conflict," during his 10 years of UHS practice.

After his experience in a clinic, where women cannot choose the doctors they want he says, "I no longer delude myself that I can be every woman's physician."

Federschenider has been unavailable for comment this week.

Other unofficial complaints about UHS appear in a "UHS file" maintained by the Women's Clearinghouse, a support and referral center for undergraduate women based in Lehmann Hall. The Clearinghouse file is intended to provide women unfamiliar with the walk-in services with-in services with reactions from other women to specific doctors. It contains good, had, and mixed reviews. The "avoid" column accumulated since the Clearinghouse was founded in 1979 include accounts of personality conflicts as well as assertations that non-gynecologist practitioners had misstated a diaphragm and failed to treat an echoic pregnancy.

UHS Director Dr. Warren E. C. Warren and several of his colleagues say they have not been aware of the Clearinghouse file until recently They add that no complaints from the file have been brought formally to UHS Justice, who has held the post since last June, and her immediate predecessor, Nancy Ryan, both say they have seen the Clearinghouse file but that none of those cases have been considered formally.

"The file is very valuable up to a certain point." Ryan says, adding that the keeps cases from the collection "It there's a special sense of dissatisfaction with the experience--say, a rooming group of six saying that several doctors are not to be trusted--then UHS should look into it," she adds.

Wacker says he personally receives between 10 and 20 UHS related complaints of all sorts per year--most of them from "nervous parents asking me about their children, which I can't tell them for confidentiality reasons "Of these, he says, "no excess" of the complaints are related to gynecologic practice. The other direct line for complaints is through the patient-advocate, who may receive a slightly greater number, Wacker adds.

During his 12-year tenure, about seven doctors have left UHS because of repeated complaints from patients, Wacker says. "Almost 100 percent" of those cases were strictly attitudinal complaints, he explains. "Most were just not suited here--they couldn't interact with students. Our older patients had had no complaints."

Both staff and outside doctors credit Wacker for improving UHS overall. "There used to be a lot of criticism of UHS" before Wacker arrived, says Edward S. Rendall, director of the health services at MIT. When Wacker took office, for example, contraceptives were still illegal in Massachusetts, and "there really were doctors and nurses you couldn't." Nancy Ryan notes.

Wacker instituted in position of patient-advocate and started some of the consumer council, she adds.

Ryan says that the majority of the complainants during her term as patient-advocate were women, many of them with gynecologic concerns. But she notes that "there has definitely been a rise in debate" on such issue in recent years, simply because of increasing national concern with obstetric issues. BWH and UHS doctors say that the broad movement among women's for "natural" childbirth and for more patient participation in the delivery process, has sparked a large proportion of the complaints against UHS. Because the University service has only two gynecologists available to women on the Harvard health plan, the matter of patient choice is also a focal point in the larger debate over the quality of campus treatment.

Since the Joint Committee's April grievance was filed, Wacker says he has arranged with Dr. Kenneth J Ryan, chief of obstetrics and gynecology at BWH, to give women on the UHS plan the option of being treated by a BWH nurse midwife instead of by an obstetrician. The midwife option had been in the works for several years, but the grievance probably spend up implementation, says a UHS consumer council member who requested anonymity.

Justice is also preparing to send a questionnaire to a random sampling of 500 women asking about their experiences with UHS obstetric-gynecologic care. The goal "to determine whether the criticisms crisps are anecdotal or pervasive," says Dr Sholem Postel, deputy director of UHS and chair of its internal quality control committee.

In addition, Wacker says UHS will begin looking more actively for a full-time female gynecologist to supplement Winig and Federschneider, rather than waiting for one of their jobs to open.

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Doctors at BWH call the Caesarean section rate issue quite separate from other gynecologic complaints. Any discussion of delivery techniques inevitably becomes tied to the national debate on the subject. BWH's Dr. Ryan, for instance, has worked on a National Institute of Health task force on the topic and sent a memo to his staff in July 1981 expressing concern that BWH's section rate was too high. He recommended a long-term review independent of specific complaints Last spring, while the review was still pending and shortly after the Joint Committee filed its grievance. Ryan took what be called the "extraordinary step" of requiring doctors to obtain a second opinion before all but emergency Caesarian section operations. Doctors familiar with the guidance disagree on whether it played a role in the recent rule change, Ryan, currently on leave, was not available for comment.

"The primary section rate is too high, and I count on all your efforts either to bring it down or prove it is justified. "Ryan stated in a memo to his staff.

But Dr. I. John Davies, Ryan's temporary replacement, notes that "no one knows what a proper rate of Caesarean sections would be. "He adds. "There isn't any date to support the statement" that the BWH rate is too high.

Other doctors argue that BWH's Caesarean rate is high because, as a teaching hospital, it serves as a referral center for high-risk and complicated cases. And they add that concern for the safety for both mother and baby sometimes conflicts with patient preference for "natural" childbirth and maximum choice for the mother, who may not want to be operated on or drugged.

"There are very sincere women who feel that the technology being applied to childbirth is unnecessary, and that teaching hospitals use too much technology, "says Wacker, acknowledging the need for continuing discussion. But the questions raised about UHS go beyond choice of technique and involve the University's responsibility to prove to women that they receive the best health care possible.