The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
|
Orgasmic Birth -- the documentary! ABC's 20/20 will be airing a segment about Orgasmic Birth on May
16th for their special Mother's Day show.
Interviews with Christiane Northrup, MD, Ina May Gaskin, MA, CPM, Sarah J Buckley, MD, Marsden Wagner, MD Joyous, sensuous and revolutionary, this pioneering film will compel many to reexamine their perceptions about childbirth. Viewers will understand how the use of normal, undisturbed birthing methods can aid the health and well-being of future generations. |
From Calling to Courtroom,
Inc. - A Survival Guide for Midwives - An online booklet with a great
state-by-state resources section in the sidebar.
Always speak about your professional midwifery
work as legal - Whether or not you are a licensed midwife, please,
please, please do not EVER say that what you/we are doing is illegal. Not
any of it, not anytime, if it can be read or overheard, i.e. in public.
Senate
Approves Patients' Bill of Rights by Wide Margin - July, 2001 [Medscape
registration is free]
FindLaw has an interesting article on Horizontal
Restraints Among Competitors, also called price fixing.
The
Trials of the Midwife
by Katie Granju - From Minnesota Parent, October 1997
A must-read article for anyone trying to understand why the healthcare
system in the U.S. continues to snub the midwifery model, despite reduced
Cesareans, proven safety, and lower costs.
The
California Health Freedom Coalition (CHFC) sponsored a law that recognizes
the professional legitimacy of alternative and complementary health care
practitioners and healers allowing them, for the first time, to be able
to legally provide and advertise their services in California.
The Intersection of Mommyhood
and The Law - Blawg Review #158 - Monday, May 05, 2008 on the occasion
of International Midwifery Day.
See also: Money and Paperwork / HIPAA
Protections
HIPAA
Compliance Resource Center [Medscape registration is free]
HIPAA Administrative
Simplification
Don Self's web
pages have some good sample forms for HIPAA compliance.
Internet Use in the Laboratory:
The webcast is approximately 60 minutes long consisting of the audio presentation
and accompanying slides.- a CME course with info about HIPAA
Final HIPAA Privacy
Rules - February 20, 2001 - from the Dept. of Health and Human Services
Their SAMPLE
BUSINESS ASSOCIATE CONTRACT PROVISIONS
Their
FAQ - Frequently Asked Questions and Answers, including "Generally,
what does the HIPAA Privacy Rule require the average provider or health
plan to do?"
State
& Territory Governments HIPAAlinks
State of California's
in-depth Office of HIPAA Implementation (CalOHI) web site. Find out
about California and federal legislation and regulations, preemption of
California State laws by HIPAA and timelines that apply to HIPAA and related
subjects, such as privacy. Contains a report to the California Legislature
on the impact of HIPAA on California State departments, as well as FAQs,
samples of templates, contracts, forms, sample implementation plans and
training plans.
Of particular value:
HIPAA 101 - Basic
information
Road
Map to HIPAA Compliance for the Provider - from the Medicaid site
CAL HIPAA - A fee basied site
about HIPAA, the Health Insurance Portability and Accountability Act, includes
strict, far-reaching requirements in 2002/2003 for an estimated 23
Million American health care providers to insure the
confidentiality and privacy of patient information.
The Midwife's Billing Service is offering a booklet (18 pages), which
distills the information that is most helpful to midwife practices.
(You can order it at 978-544-3551)
The Emergency Medical Treatment and Active Labor Act (EMTALA) has specific regulations for hospitals relative to women in active labor. The purpose of these federal regulations is to ensure that patients with medical emergencies, including women in labor, are not denied treatment based on any reason other than those that reflect the hospital's capacity to examine, conduct tests, and treat the emergency condition.
All women in true labor are considered to have an emergency medical condition, and are therefore unstable. "Labor" is defined under EMTALA as the process of "childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta."[1,5] The presence of an emergency medical condition triggers all of the obligations of EMTALA.
This is taken from the Winter 2006 - Number 76 issue of Midwifery Today:
"The federal Emergency Treatment and Advanced Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment wishes until the baby and placenta are delivered. The act was originally passed to prevent hospitals from "dumping" patients who can't pay, but its since been applied in all sorts of other ways and includes specific provisions that apply to laboring women.
The attorneys we've consulted on the VBAC ban issue have told us that hospitals are much more afraid of being found in violation of EMTALA than they are of malpractice suits because the act is routinely enforced and each violation subjects them to fines between $50,000 and $100,000.
I can't emphasize enough the importance to individuals who may find themselves in this situation of memorizing phrases such as "It's a violation of my rights under EMTALA to force me to undergo a cesarean," or "I'm invoking my right under EMTALA to refuse a, b, c." Whether the hospital in question says it bans VBACs is unimportant; according to EMTALA, you have the right to be admitted to a hospital once you're in active labor and, once admitted, you have the right to refuse any recommended treatment. You can also remind them that VBAC isn't a treatment, it's the natural culmination of a normal physiological process. Cesareans are the treatment.
Also, it's helpful to know that EMTALA begins to apply once you are anywhere within 250 feet of a hospital; you don't have to be in the emergency room. You can be standing in the hospital parking lot, and if they so much as touch you against your express consent, they are in violation of EMTALA. For anyone interested in reading more, we've compiled a legal primer on the rights of pregnant women at http://www.birthpolicy.org
Editor's Note: To learn more about this important subject, go to
Leaving
against medical advice: Should you take no for an answer? - Free CMEs
- This course will discuss the medicolegal risks to the physician, nurse,
and hospitals associated with a patient leaving against medical advice
(AMA) and provide strategies to prevent patients from leaving.
Informed
Consent: Practices and Views of Investigators in a Multinational Clinical
Trial [9/27/05 - Medscape registration is free]
MIDIRS offers Informed
Choice leaflets
ACOG
can be a good source for patient education pamphlets aimed at good liability
defense.
Doctors
spell out risks of childbirth on consent forms [August 09, 2004]
- Seven Seattle obstetricians are drafting a consent form for pregnant
patients, spelling out in graphic terms the dangers their babies face coming
into the world, including death, "permanent severe brain damage" and other
lifelong disabilities.
I wasn't sure whether to include this in the subsection on "Informed
Consent" or "Lack of Informed Consent".
Getting a stubborn patient to say Yes
- an article written by and for OBs about how to coerce laboring women
to agree to routine treatment.
This is the actual practice of the theory expounded in Patient
Choice and the Maternal-Fetal Relationship.
(2) The physician's duty is to provide appropriate information, such
that the pregnant woman may make an informed and thoughtful decision, not
to dictate the woman's decision.
(3) A physician should not be liable for honoring a pregnant woman's
informed refusal of medical treatment designed to benefit the fetus.
(4) Criminal sanctions or civil liability for harmful behavior by the
pregnant woman toward her fetus are inappropriate.
(5) Pregnant substance abusers should be provided with rehabilitative
treatment appropriate to their specific physiological and psychological
needs.
(6) To minimize the risk of legal action by a pregnant patient or an
injured fetus, the physician should document medical recommendations made
including the consequences of failure to comply with the physician's recommendation.
(BOT Rep. OO, A-90; Reaffirmed: Sunset Report, I-00)
[From the AMA Guidelines.]
Words: Stark
Foundations of the Euphemisms that Bind our Times - Words are used
to control pregnant women: "evidence based practice", "woman centered",
"choices in childbirth", "informed consent"- these terms mean little when
medical application can be so ruthless. [As of spring, 2002, the
BirthLove site is by subscription only - it's well worth the $10 membership
fee; you can get a "sampler" by reading BirthLove's
Top Twenty- For Free!.]
Informed
Consent Clouded by Technology, Marketing Pressures [Medscape registration
is free]
Federal
Legislative Draft Mandating Patient Empowerment and Medical Accountability
- this is well worth reading for anyone who values the concept of true
informed consent or informed choice.
I don't know about c/s situations, but I do know that any medical procedure
that a person says "I do not consent to _______." in Texas is considered
assault if the provider does the procedure in spite of the patient.
It's a great sentence to teach moms about episiotomies.
ICEA Statement on Informed Consent
Jude Stensland's collection of Consent
Forms and other information sheets
Faith
Gibson's pages on Informed Consent for Special Circumstances
A
comprehensive set of Informed Choice leaflets from the folks at MIDIRS
(Midwives Information and Resource Service)---- each examines
key decisions facing expectant mothers during pregnancy and is designed
to assist them in making informed choices. Vitamin K, Rho-gam,
Ultrasound, Home, Hospital or Birth Center, VBAC, Breech.
Regarding those universal consent forms hospitals typically use,
Consent may be given or withdrawn at any time, either verbally or orally.
You can sign a consent for episiotomy on admittance but when the time comes
if you say no don't cut me and the doctor still does, that is tort
battery. MGC continues on the same page:
My psychiatrist husband (director of a state psychiatric hospital) reminds
me that only the court can determine competency in the U.S. Physicians
have no legal right to do so. Patients are presumed competent unless an
interested party (usually the family, sometimes law enforcement, less often
the hospital or physician) petitions the court and a judge rules the patient
is not competent.
Any time a physician or hospital staff performs any procedure on any
patient without the patient's consent (or the parent or guardian's consent
in the case of a minor or incompetent adult), battery has been committed.
Battery is a tort, but is an intentional tort not covered by most malpractice
policies. It does not require financial damages as a medical malpractice
(negligence) tort does.
So, I'd be careful about doing anything without consent, even if you
think the patient needs it, and I don't use blanket consents to treatment.
There's not a lot of money in battery lawsuits for attorneys, but some
are noticing that since the malpractice policy doesn't cover it, physicians
are more likely to settle quickly, so there's potentially less work for
the attorney.
I guess my health law and patient's rights classes at the school of
public health impressed me.
But, just so everyone knows, if you do this, the nurses are required
by law in some states to inform Childrens' Services. And, if you
get out of the hospital before they arrive, they will call or show up at
your home and put you through a thorough investigation. This happened
to my mother with her 3rd child (taken to hospital for jaundice after a
homebirth) and it was a threat made to me when I said I would check my
2nd son out AMA if they didn't stop trying to replace his IV. It's
not something to be afraid of, per se, just be aware that it could very
well happen.
i would like to relate an incident that happened in a hospital that
was not related to birthing. my son when he was little had moderately severe
asthma. he was admitted to the hospital on one occasion for treatment.
they had to monitor the levels of the medication in his system, which required
drawing blood. he was only 6. one lab tech decided she was going
to take the blood while he was asleep. i told her to wait until he
woke up. she said no. i said you WILL wait. she started to
do it anyway- i called the nurse. before the nurse got there,
my son was screaming at the top of his lungs and so was i (how would you
like to wake up that way!!!). the only way i could have stopped her
was by physical force. and i guess i could not believe she was really doing
it when i had explicitly told her NO!! this officious little snot
of a lab tech defended herself by claiming she had a schedule to follow.
the nurse was appalled. we did not see that little snot for the rest of
his stay. one of the peds nurses did the rest of his blood draws-WHEN
HE WAS AWAKE!!! grrrr.....
i guess my point is, some hospital personnel will have a difficult time
taking NO for an answer, so we need to be prepared to fight if we have
to!
Do we have a right to get up and walk out of the hospital during labor
after we admitted to the L & D? Is it legal to do that? Will the guard
arrest us if we do that? Do we have a right to go to the nursery and pick
up our baby and walk out of the hospital without signing the discharge
paper? Is it legal to do that? Will the guard arrest us if we do that?
I find it disturbing that culturally we give so much power to the medical
system.
Why would it ever be illegal to leave the hospital? You're not
supposed to be under house arrest. You're not supposed to be a prisoner
of the state.
In theory, doing something to your body against your will is battery,
and trying to hold you against your will is kidnapping.
You can even decline any and all procedures offered, even a cesarean.
If they do a cesarean against your will, you have a whopping big lawsuit
on your hands. Why do you think they're always shoving consent forms
into your face? I know it seems like a formality, as if they would
do whatever they wanted anyway, and it's just a nicety for them to pretend
that they're carrying out your wishes, but that's how it's supposed
to be.
It bothers me when hospitals rob patients of their individual freedoms.
First, they're getting court orders to perform cesareans, then they're
putting pregnant women in jail because their behavior might affect the
baby. How long will it be before they seek court orders against women
who don't eat their vegetables? The only thing holding them back
is the numbers of such women, not the principles involved.
One thing I learned when my instructions concerning the baby were not
followed despite having watched the document being stapled to my file is
that the baby gets a file of his own and your instructions will not necessarily
be transferred to his file. So, if you have birth instructions and
post-birth/baby instructions, make sure to have two separate documents
and be sure your support person gets the baby's document into the baby's
file and still monitors staff to make sure your instructions are followed.
After baby #1, my husband and I have an understanding that no matter
what is happening with me, he is to stay with the baby. Despite my
express written instructions (for the child of two lawyers no less!), the
nurse never looked at the document and my husband had to stop her from
putting antibiotic cream in his eyes. I feel sure he will have to
do it this time as well. The hospital registration documents included
a hep b consent form. I didn't just check "No" and sign - I added
an addendum that any injection given to the child without the informed
consent of the parents would be deemed a battery and would be the subject
of legal action.
You can just never be too loud that you don't want your birth and/or
your baby's treatment to be done with everyone on auto pilot.
Preganant
woman's rights get short shrift - OB and lawyer get court order to
force a woman to submit to a cesarean against her will.
Our office has 4 pre-printed forms, on 8 1/2" by 5 1/2" (1/2 of sheet
of standard typing paper); each of these has our office letterhead across
the top, so it looks "official", and is on NCR paper; we give the client
the original and keep the copy in her chart.
All the forms have a space for the date at the top, and our signature
at the bottom. The 4 forms are:
New York - Class Action Suit for Homebirth Rights
Abby Odam and Birthing Rights in California
Even if home-births ( in low risk women ) were less safe than hospital
births ( which they aren't ! ) then it is still a matter of choice.
As a gynaecologist I see lots of women with heavy periods despite medical
treatment. Many of them opt for surgical treatment - rather than the other
option of putting up with the nuisance until the menopause. Now it's widely
known that just occasionally a woman dies after routine gynae surgery (
very rare fortunately ). No-one ever dies from heavy periods. Don't all
these women ( and their ob/gyns ) realise that avoiding surgery would be
overwhelmingly the safer option ? Actually the women and their MDs simply
make an informed choice about quality of life - and there's nothing wrong
with that - no matter what the context.
There are some people that have some serious concerns about the recent
decision in CA about midwifery. There is a major distinction between misdemeanors
and felonies in the CA law. If anyone dies during the commission of a felony,
whether the deceased is called the victim, a bystander or even a perpetrator,
whoever is convicted of that felony is also guilty of felony murder.
The constitution of the United States requires laws to be made in the
Congress. The Court's function is to interpret these laws. California has
historically used the courts to usurp the powers of Congress by making
law through judgments or precedents.
Midwives be advised regardless of the recent licensing laws in the state
of California, this recent court decision has made the practice of midwifery
illegal. It is now more illegal then it was before.
Keys
to minimizing liability in obstetrics By Gary Ventolini, MD, Christopher
S. Croom, MD, and William W. Hurd, MD
Caesarean Birth Verdict
A jury has awarded more than $1.5 million to a woman who sued her doctors,
claiming that the unnecessarily delivered her child by caesarean section.
The verdict is unusual, lawyers say, because while malpractice cases
are often filed in cases in which a mother or child is injured because
doctors failed to do caesarean surgery, patients rarely sue on the grounds
that a caesarean wasn't necessary.
In the case, which was filed in Cambridge, Mass., the woman, Mary Measdor,
developed an intestinal illness which she said was triggered by the caesarean
delivery. Her doctors, Stanley Stahler and Ruben Gheridian, said that she
had consented to the procedure.
Suffering, not malpractice, guides medical suits
Case Dismissed - Hopes for Appeal
But it bothers me even more to think that it's possible that a midwife
might actually have done the things the they are alleging. And it's somewhat
unsettling to realize that some people think they shouldn't make a fuss
about their perception that they were grossly mistreated and have suffered
real damages from unnecessary surgery.
I spend a great deal of time on lists run by/for birthing parents -
the ICAN list and the homebirth list.
There are a lot of unhappy folks out there, and a reasonable share of
them have complaints about midwives. Appalling as it seems, there do appear
to be midwives who do not always provide the best possible level of care.
It really isn't enough just to try to do a good job, in the sense
of wanting the best for the clients. We actually have to come through anddo
a good job, even when that means providing a referral or calling in backup.
I would like to think that all midwives come from a place of good heart
about their work and are dedicated to providing the best possible care
for the families they serve. And the times when I see midwives fall short
of their own objectives are usually times when the midwife ran short on
time and/or energy.
It sounds as if this might be what happened in the their case; a midwife
with an unreasonable case load behaving in ways that maybe aren't in the
clients' best interests.
Is it really such a bad thing for each of us to take this opportunity
for some introspection?
Are you making commitments you can't keep? Do you have good midwife
backup? Do you reduce your caseloads when a partner is on vacation? If
not, do you let your clients know that this may compromise their care?
Do you solicit feedback from clients after their last appointment or do
you just assume that everything must be fine if they didn't complain?
And, most importantly of all, are you being absolutely honest with your
clients about what kind of care you are offering?
I have absolute tolerance for any and all styles of midwifery practice
that are made clear to the clients.
I won't criticize a midwife who tells her clients at 40 weeks that they
either have to agree to a pit induction or have their care transferred
to an OB, as long as this possibility was made clear to the clients.
And I won't criticize a midwife who doesn't try to change a posterior
or asynclitic head, as long as she makes her style of practice clear to
the clients beforehand.
I don't care whether a midwife goes strictly by the book or hasn't cracked
a book in years, as long as this is made clear to her clients.
But it galls me that there are midwives who hide behind the veil of
purity and expect that having answered the sacred call of midwifery somehow
puts them on a pedestal above criticism, regardless of how they may have
misrepresented the kind of care their clients can expect.
Some of this week's discussion on the ICAN list has been about the very
deep loss that they feel around their birth experiences, "even with a live
baby". Many of them feel deeply wronged, and I agree that most of them
received lousy care and have a lot to be angry and sad about. I'm one of
those who happen to think that they have an obligation to themselves and
to their families to process these feelings, rather than simply "getting
on with their lives", which really means suppressing their feelings.
Hearing you telling them to put it behind them sounds a little like
telling parents who've lost a baby that they should be happy because they
still have healthy ones at home and/or can still have more babies.
Gosh, why is it so hard to accept that some people have really horrible
birth experiences, and some of the caregivers involved might have been
midwives?
There have been times when I have not provided the best possible care
to my clients. Given that I'm a relatively new midwife, these have been
from lack of experience rather than lack of time or energy. But I am crystal
clear with prospective clients about my training and experience, and I
tell them that I cannot "play the edge" the way a more experienced midwife
might. And I have done my share of apologizing to clients when I've been
wrong.
I have never knowingly lied to clients to CMA, and I hope and pray that
Grace will provide me with the strength to keep that true.
And if the fear of betraying my own integrity and my very serious obligations
to my clients isn't enough to make me do my very best, then let it be the
fear of arrests and lawsuits.
But I do not believe that I have a responsibility to provide blanket
support for everything that is said and done by someone just because she
is a midwife. In fact, I believe that I have an obligation to condemn mistreatment
by any care provider, regardless of what they call themselves. And I hereby
openly condemn any care provider who recommends unnecessary surgery simply
because they do not have the time, energy or patience for the situation
at hand. This is no more acceptable from a midwife who is exhausted than
from an obstetrician who wants to make his tee-time, although it may be
more forgivable.
We, the midwives, are supposed to be serving them, not the other way
around.
I know how easy it is to 'fall into planning and arranging care to fit
the schedule-of docs, nurses, hospital, myself'. I did that soon after
getting out of school, and when i became conscious of it I was so appalled,
cuz I had previously consciously thought i would never do that.
You do what is best for the patient, not what you think will look best
to a plantiff's attorney. If you think something is best for the patient
and you delay because of malpractice concerns, then you are acting for
your own interests and against the patient's interests, and the only word
for that is "unethical."
Complexity
by Method (from The Clinical Laboratory Improvement Act (CLIA) and
the Physician's Office Laboratory: Introduction)
CLIA Waived Test
List - updated 02/02/2000 - from the Public
Health Practice Program Office at the CDC
CLIA
is Clinical Laboratory Improvement Act. Each medical facility of any kind
that does any blood or urine testing is supposed to be listed with CLIA.
The purpose of CLIA is to keep labs on the up and up. You have to be trained
to run tests properly and you have to have a medical director who oversees
the operation of laboratory testing. If you think about this, it is a good
idea. Suppose a docs office (or one of the rich midwives!!!) hires some
teenager to come in and run their gestational diabetes testing for them.
They are shown the machine and told here's the book, do the testing. This
kids messes up and everyone has GD and is treated with insulin. This happened
here in Arkansas at the HD with hemoglobin testing with the hemoglobinometer.
The nurse got a 9 on a kid's Hg and sent her to the doc. The doc sent the
kids back with a 14. They drew blood and the Hg was 14. A real embarrassment
to the HD and a possibility for suit.
Back to the topic at hand. So the government comes up with this CLIA
thing and here in Arkansas the Health Department sent out a letter to all
the midwives saying that we were to be CLIA certified also. And yes, you
could get into trouble if you aren't registered with the government. But
how are they going to find you.
I've had a CLIA certificate for about 5 years now.
All the tests that we actually run are called "waived tests". Only labs
or big offices actually do any of their own testing any more. Collecting
the specimen and sending it to the lab does not count. Running the test
is what is monitored.
Waived tests include urinalysis for the things we check for, Hg, Bg,
etc. Any dip stick tests and any machines that spit out the answer. With
the hemoglobinometer, you are making a judgment call and thus they think
it is not a waived test. The Hemacue since it gives you the results like
the Accucheck does is considered waived. No room for human error, supposedly.
But the problem is that the Hemacue as I understand it costs about $600
or something like that. Enough that I never checked into it. My hemoglobinometer
may not be that accurate but I use it anyway.
I would think that all state licensed midwives would all have to have
a CLIA certificate. It basically states that you do not run other tests
besides the waived tests. To get a certificate to run higher classed tests
can cost up to $10,000.
I think the next level up from waived tests costs $1000. These are fees
for every 2 years.
Any time you do any laboratory testing of any kind you are supposed
to be registered with CLIA. That includes urinalysis such as we do. It
also includes Hg, Bg, etc. These are all waived tests. Don't require too
much expertise.
To do microscope tests, other more specialized, you are supposed to
be properly trained so as to get accurate results. CLIA was begun to regulate
laboratories so as to get accuracy in testing. But CLIA has made doctors
offices have to stop doing testing even. There are so many regulations
and inspections to deal with. And the fee for advanced testing can run
into the tens of thousands. I pay $100 every two years to have a waiver
for the easy testing.
How have you been able to initially contact and TALK to OB/GYN's about
being your consulting/collaborating physicians? And how have you formalized
that agreement?
My dilemma is two-fold. I am a new graduate nurse -midwife and in my
state- Arizona- I need to have a physician listed on my application for
a state license as my "official" collaborating physician. I have sent out
resumes (Unsolicited "cold calls") to every OB in the area who I would
be willing to work with, and have made follow-up calls with little results.
I can't even seem to talk to them on the phone, let alone set a time to
meet with any. They are either out of the office, seeing pts, doing procedures
or......you get the picture. I am thinking that the letters and resumes
are being screened by the office manager and/or nurses in the office so
the docs may not even know about me. I work full time +, and can't afford
to sit in offices on the chance that maybe I can have an impromptu meeting-
plus it would be impractical....
Any suggestions?
Ask them out to lunch
Would someone please clarify the legal authority under which a midwife
is licensed to practice without medically approved protocol and physician
back-up in any of the states in the U.S.? This assumes that there is a
relationship that involves charges for services.
In Maine, the Medical Practice Act specifically excludes vaginal delivery
from being defined as a medical procedure. There are both nurse midwives
and lay midwives practicing throughout the state doing home deliveries.
We have a fairly cordial relationship with the lay midwife in our county
because we decided long ago that an adversarial relationship would only
interfere with care of her patients who needed hospitalization. I haven't
heard of any breech home births in our area but I do know of several VBACs.
When I mentioned to the midwife that I didn't consider VBACs low risk and
suitable for home delivery she sent me the A.C.O.G. literature touting
its safety. Hoisted by my own petard!
My partner and I are the only CNMs doing homebirths in this state. Both
of us were direct-entry midwives before becoming CNMs. So we both were
ingrained in OOH birthing. I have a birth ctr, so we do birth ctr and home
births. Contacted, met with a group of OBs about being our "back-ups".
We asked for a lot at the beginning -- i.e. chart review, etc. Worked out
what they were willing to do after they consulted with their malpractice
insurance co. and attorney. What we ended up with in writing is a letter
stating they will accept our clients if transferred to the hospital. Not
much different than they do for any other walk-in. That's what we have
in writing, and what I use whenever written confirmation of back-up is
needed.
In reality, these 4-5 OBs have been very helpful and respectful r/t
consultations, referrals, transports, etc. I guess that they just can't
have a formal, written agreement d/t liability issues. But they know what
we had wanted and asked for at the beginning -- more of their input towards
our practice (which we didn't necessarily truly want, but showed our intent
to work with them). One of these OBs is always on call, so have had no
problem with transports, etc. Anchorage is overrun with OB practitioners
-- OBs, CNMs, DEMs, perinatologists. So perhaps they just want our business,
that's okay. This group has 5 CNMs working with them so they already are
pretty much midwife friendly.
We don't have hospital privileges either at this time. Difficult to
find an OB to sign as preceptor for an independent midwife. The preceptor
form at both hospitals here state, "I will be totally responsible for this
CNM morally, ethically, and financially." Hard to even sign such a statement
for your own kin! Had tried to get the bylaws changed at one of the hospitals,
it was shot down by the perinatologists, OBs. I'm sure a lot of it is because
of the high competition for clients at this time here -- comes down to
reduction of income for them if they let those independent midwives in
the hospital too!
I think you're right - it IS more difficult to be a CNM in homebirth
practice because of physician opposition. We are educated within the medical
system and are supposed to function within the medical system, and that
works as long as we do what we're told by the powers-that-be. When some
of us want to do homebirths, or even independent practice with hospital
births, it can get pretty sticky pretty fast.
There are no doctors in this area who will "back" me for doing homebirths,
which was a major obstacle at first. I even called the ACNM to find out
exactly what it means to have a "arrangement" (or whatever word is used)
with physicians - does it have to written, how informal can it be, at what
point do I get into trouble, etc. The answer I got is that it depends,
but basically there must be some avenue to get more specialized, intensive
care for clients who become high-risk. In this area, I know the docs and
nurses because I've done hospital births here for seven years prior to
starting a homebirth practice. That was a big advantage for me because
I knew what they thought:
It may be that this works only because I'm in a smaller town where there
are only 6 OB/gyns split between 2 groups/hospitals. All I know is that
despite my fears and the dire predictions of others about the possible
success of starting my own homebirth practice, I've managed to do it. And
I think already having a reputation within the medical community has helped.
The docs have lots of liability concerns about being responsible for what
I do (which is why I'm no longer employed by them), but seem to have little
beef with me doing my own thing (as long as I don't take too many of their
clients, I'm sure).
The problem is that I had to relinquish my hospital privileges since
I don't have a physician "sponsor" - someday I'll work on changing the
bylaws to something more workable for me. I do have outpatient privileges,
though, so can order labs, sonos, NSTs, etc.
I don't know that "supervise" is the best word to use, at least in my
state. In Montana, a CNM is an independent provider. Collaborative relationship
might be a better term to describe the relationship between the CNM and
MD.
"Supervise" is definitely the word here in California. The laws
for CNMs and DEMs both state that the midwife works "under the supervision"
of a physician. We dream of being recognized as independent providers.
Actually, we do more than dream, we're trying to change the language
of the laws. Our bill got killed last year, but we'll be back!
My partner and I are currently negotiating with a group of OBs to sign
as our preceptors to obtain hospital privileges. Their biggest worry
at this time is that they would have to do chart review for us. They
have been backing us up for 4 years on our home and birth ctr births.
But to sign on the dotted line for privileges is another matter.
In the past they have done backup for nothing, but got all our referrals
to the hospital.
I have a letter from my consulting OB that states that he has "agreed
to accept referrals and consultations" from me. It satisfied my hospital
requirements. He is only responsible for the actions he takes, not
for my actions. Our Family Practice docs essentially have the same
requirement for OB patients.
Letter to Doctors Requesting Backup
This is a new section - please e-mail me information about your state
if it's useful here. Thanks.
California Bill SB255 Fails to Change "Supervision"
to "Collaboration"
Colorado does not require supervision but the instances are spelled
out for when we need to consult. Our
rules are in serious need of updating.
When I had an emergency transport with my first homebirth, I was just
stuck with the doctor on call because according to law my midwife has to
transfer me to the nearest hospital capable of handling my "emergency"
so her back-up doctor didn't really do me any good.
My midwife does have an MD who is her back-up, but unfortunately, he
practices in a town not very convenient to most of us in the metroplex,
so although she can consult with him about various things, he rarely would
be "available" to take over a delivery that had to be transferred, due
to his location/hospital privileges being not the "nearest."
After I transported a VBAC client into the local hospital, the receiving
OB took me aside and raked me over the coals. He said if he ever
heard of me doing another VBAC he would put me in jail. He said he
was supportive of homebirth and that he would even do it himself if he
could. He said 99% of women are safe to birth at home, then he even
said that I could do a 2nd or 3rd etc. VBAC, but not a first-timer.
He said he would find me- I couldn't hide.
I would send him a letter confirming that was what you heard of your
conversation. I would have a place for him to sign his name and to
return the letter to you for your records. I would consult a lawyer
for harassment and notify him that he is no longer allowed to THREATEN
you for being a good and caring citizen. Don't let some fearful and
VIOLENT man prevent you from doing what you know in your heart is right.
How does an independent practitioner actually go about obtaining hospital
privileges?
Here in Oregon a CNM calls the medical staff office of the hospital
and requests an application. The response will include all the requirements.
These may include your CV, evidence of malpractice insurance, a documented
affiliation with an OB/Gyn for high risk consultation and surgical services,
letters of reference. Then the application and documentation will
go through all the hospital committees which usually only meet once a month
so the process will take at least about 6 weeks. Unless this is a
totally new entity at the hospital. In our case it took 10 months
to change the necessary policies in regard to affiliate medical staff status.
If your hospital has nurse anesthetists with privileges check out the rules
and regs that apply to them. Medical Staff Office is the place to
have friends and start investigating. There is a hospital here in
Eugene that restrains the trade of midwifery practice by requiring employment
by physician or hospital to be on staff. Be persistent, positive,
and friendly.
See also: Asset Protection
Issues
and Allegations: Medical Malpractice - A nice overview of the issues
from The American Voice 2004
American College of Domiciliary Midwives - Community
Midwives Malpractice Insurance Consortium
Courts Rule Against Increased Malpractice for
OBs working with Midwives
MALPRACTICE INSURANCE Midwifery Insurance Program
Available in Florida Low cost - not based on the number of births you
do. It covers home, birth center and hospital births. Their research said
we were a safe risk :-)
Has anyone practiced bare and then obtained insurance? I am running
into a problem with my consulting physician's insurance company and their
unwillingness to issue her vicarious liability because of a perceived risk
if there is a claim made from the time I was bare.
Why is the doc getting vicarious liability? Has new info come out since
Susan Jenkins the ACNM lawyer wrote the article "the myth of vicarious
liability"?
Her carrier is requiring that she have vicarious liability in order
for me to work for her. They will not issue it unless I can get coverage
for my practice during the time I was bare (1985-1998). Of course, no insurance
company wants to provide coverage retroactively #1, and #2, I was a licensed
midwife not a CNM, and there was no coverage available. (I have been a
CNM for 6 months). Her company is claiming that even if they are not insuring
me, if I am working for her and someone I delivered say 8 years ago decides
to sue me, she would be liable since I am her employee! Any advice most
welcome. They have said they would not issue coverage until the youngest
baby was 21 that I delivered bare. The Doc says, well it's just such an
unusual situation. I say no, there are hundreds of midwives who have done
homebirths bare and then been able to go on and work for Dr.'s. So help
me. Share your stories. Perhaps they will help the insurance company see
the light!
This really makes no sense. Why would this MD be responsible for
births you did before you were involved with each other? I don't
see how there would be any way someone could sue you for a birth many years
ago and be able to name this MD as anything to do with it! I mean,
it seems it would be easy to prove that you had nothing to do with each
other at that time.
I was a direct-entry midwife for many years before I became a CNM.
None of the OBs that we have talked with have ever mentioned coverage for
births prior to when they became involved. We are negotiating with
a group now. We currently do homebirths. They said that if
they sign as our preceptors in order to get hospital privileges that giving
up homebirths may be a condition. They never mentioned any tail coverage
for these past births. We have never had malpractice ins for homebirths,
only for birth ctr ones (costs twice as much to cover the homebirths!).
Oh this type of coercion makes me so upset! I have a homebirth practice
and have been working at changing the bylaws at the only hospital in the
county, it was in the lawyer's hands last I looked at it, and is to be/
or should be by now independent hospital privileges, but I live 40 miles
from the hospital, and they demand within 20 minutes or have someone on
call for you.
I was told by the ACNM Ins co. that a CNM can attend both home and hosp
births, but only the hospital births will be covered by the malpractice
ins. There is an option through another co that will cover home birth,
but the cost is VERY unreasonable.
CNM's and other practitioners do need malpractice ins to have hospital
privileges, at least in AZ.
Recently I was told you are suppose to ask the caller if they are an
investigator or do you work for the health dept? something to that effect-
they aren't supposed to lie if asked directly. ( sort of the hooker approach-
these older professions you know ; ))
When I practiced illegally I lived in a state where it WAS NOT a felony
and no one had ever been convicted. Many of the openly practicing MWs had
gotten c&d letters few took it to heart. The state just didn't have
the funding nor the volition to get hard core about us. So this is definitely
not your situation, if the AMA has targeted your state, they have probably
lobbied for some sort of investigative funding... if the labs have cut
you off , how about sending away, or a friendly doc, naturopath , chiropractor?
If they order labs this is legal for them to do, and you can get a copy.
The way I've seen it done is to figure out what the letter of the law
is then figure out what it doesn't include. Practice in the loop-holes,
still could be dangerous but often dependable. What does your lawyer suggest?
The first rule for apprentices and midwives: DO NOT TALK TO ANY AUTHORITIES!
DO NOT EVER AGREE TO AN "INTERVIEW"! DO NOT TALK TO ANY PERSON ABOUT ANY
CRIMINAL MATTER WITHOUT ANY ATTORNEY PRESENT!
We've had a few cases over the years in our region. Every single time
(to the best of my knowledge), any person who agreed to an "interview"
was charged, or "had to" turn evidence through fear of being charged.
Any time an interview was refused...... nuthin' ever happened.
Ya DON'T talk to any government agent when they're going on a fishing
expedition!
They can seem so nice and charming and harmless. But that's their job!
to SEEM to be friendly and to get us to trust them, and to talk to them.
And anything we say can be twisted into something which harms US!
The hearing was canceled and eventually all the charges were dropped.
Encouragement and Moral Support for Midwives
Under Siege
Also read What
Do Trees Have To Do With Peace? - the story of Dr. Wangari Maathai,
the 2004 Nobel Peace PrizeLaureate.
There's a great article - Midwifery
is not the practice of medicine by Suzanne Hope Suarez, in the Yale
Journal of Law and Feminism, Vol 5, No 2, Spring '93.
NARM Position
Paper on the Practice of Midwifery - "The practice of midwifery is
a distinctly separate profession from the practice of medicine or nursing."
Midwifery Today has a Forum
on Legal Battles and Birth Politics
A Battle for Body
and Soul by Carolyne Pion - about Karen Hunter, a Maryland midwife,
arrested in 2002 or 2003 for a birth in 1994 and about legal discrimination
against homebirth.
A Current Summary
of Breastfeeding Legislation in the U.S. - a state-by-state guide to
breastfeeding laws in the U.S. from La Leche League.
Text
of Adopted Decision in case against California Licensed Midwife Alison
Osborn Administrative Law Judge dismissed charges after extensive hearing
(August 20, 1999).
Amicus brief
filed by California Citizens for Health Freedom
Amicus brief
filed by California Citizens for Health Freedom
In Denmark it's any woman's right to give midwife-assisted birth at
home. She cannot be refused, irrespective of whether she has refused the
routine datings or not. Midwives/doctors will probably try to persuade/recommend
her to go to the hospital - and may also "label" her a high-risk. But the
woman has the law on her side. The recent 20 years I think, the home-birth
rate in DK has been 1-2 %.
European Cases
Against Midwives - from Sheila
Kitzinger's site
Debra
O'Conner, CNM, in Washington State (January, 2002)
Kellie
Sparkman in Nevada (March, 1999)
Maternal Death
in North Stafford, Virginia - midwife Cynthia Caillagh (late 1998)
Amy Medwin - North Carolina
Seeking information about maternal death at El Camino Hospital in Mountain
View, California in 1997 or 1998, thought to be from a post-cesarean infection.
Please
e-mail any information. Thanks.
MANA's Guide - Direct-Entry Midwifery State
Legal Status as of 9/96.
Motherstuff
- Midwifery-Related Law
California's
Licensed Midwifery Practice Act of 1993 - Also see Notes
for California Licensed Midwives
Citizens For Midwifery
- State By State
Current midwifery
battles in U.S. Courts.
Illinois Midwives
Homepage (re: 1997 legal situation)
A Mother's Letter to Illinois Gov Edgar
Minnesota Families for
Midwifery
M.A.N.Y. (Midwives
Alliance of New York)
New York - Class Action Suit for Homebirth Rights
5/31/97 Update on New York Class Action Suit
5/31/97 Update on New York Class Action Suit
- Morning Session
Martha Hughes - Midwife Prosecuted for Breech
Death
Beah Haber - Midwife Lost
Privileges at Valley Care Center in Pleasanton, California.
The Boots at
the Door
Abby Odam and Birthing Rights in California
California Bill SB255 Fails to Change "Supervision"
to "Collaboration" for CNMs
Midwife Leaves Illinois After Legal Harassment
Kansas Court Proclaims DEMs Legal
Entire Ruling of the Kansas Supreme Court re:
midwifery
Bloomington
Indiana Midwife - Jennifer Williams, CPM
Midwife’s
arrest protested [1/16/06] - Indiana has brought felony charges against
long-time midwife and CPM Jennifer Williams for practicing medicine without
a license and practicing midwifery without a license in Shelby County,
Indiana. After 17 years of practice without incident, she was brought to
the attention of authorities because of a stillbirth, and after an investigation,
was found to have acted appropriately both in the delivery and her response
to the emergency. (Please note that the news account has some
inaccuracies – for one thing, the baby died of asphyxia, ie, was stillborn;
any cephalhematoma was incidental, and the midwife does not own and never
used a vacuum extractor.) The parents are completely supportive of
their midwife.
Midwifery Persecuted in New York State
Roberta
Devers-Scott Sued in 2005 - A former Mendon (VT) midwife and one of
her students is being sued by a woman who claims that her 21-month-old
son suffered permanent brain damage during birth.
Press Release regarding Citizen Support for Roberta
Devers-Scott
Roberta Devers-Scott's Court Statement in response
to Misdemeanor Charges 9/23/96
Women In Wisconsin May Lose Civil Rights During
Pregnancy
Medical
Records Release Forms in both .pdf format and .doc format, which you
could tailor.
Don Self's web
pages has a sample form for "divorcing" a client from your practice.
Terminating
a Patient: Is It Time to Part Ways? [09/20/2005] by Deanna R. Willis,
MD, MBA; Ann Zerr, MD [Medscape registration is free.]
Sample Termination Letter
When you decide to end your relationship with a patient, inform him
or her in writing and send the letter by certified mail, with a return
receipt requested. If it's possible to describe the reason for the termination
in a brief, clear, objective way, do so in the letter. If not, you might
be better off not providing a reason. The patient ought to be aware of
the reason as a result of earlier discussions and correspondence. Some
malpractice insurance carriers offer sample termination letters, or you
can adapt the following sample.
Dear [patient name],
As you know, a good relationship between a physician and his or her
patient is essential for quality medical care. There are times when this
relationship is no longer effective and the physician finds it necessary
to ask the patient to select another physician.
This letter is to inform you that I am no longer willing to be your
primary care physician. The reason for this decision is [describe reason
briefly, or omit this sentence]. Our office will continue to direct your
care for any emergencies that arise over the next 30 days. It is imperative
that you select another physician and arrange with our office for your
records to be sent to your new physician before [date]. Your insurance
plan or the local medical society [insert contact information] will be
able to assist you in choosing a new physician.
Sincerely,
I sent a pt a divorce letter and a refund check via certified mail.
She knew we were sending her a refund because we spoke with her the day
prior and told her how much she would receive. She refused the certified
mail and my question is: What do we do now as far as divorcing her and
do we still owe her a refund?
If the letter that is sent via regular mail (be sure to document that
you sent these this way when the certified letter was refused) does not
come back AND when the canceled refund check comes back, you can safely
assume that she received the letter.
You may want to check with your attorney, but usually, if you send one
certified and one at the same time, regular mail, it's considered "fair
notice". Put the refused certified receipt, uncashed check and copy
of letter you sent in her file and then forget about it. If you haven't
sent one regular mail - go ahead and do it and then honor that letter -
whatever it says.
As far as the refund, was it an overpayment, or were you refunding simply
because you are divorcing her? An overpayment you still owe, but
I never believe in giving money back just to shut people up. As far
as the letter goes, if certified mail is refused I send the letter in a
plain envelope with just the street address as a return, so they don't
know who it is from before the open it. You can't be positive that
they received it, but if it doesn't come back you can be pretty sure.
I would write them a letter telling them, in detail what Midwifery care
is all about, i.e.: Shared responsibility, etc., and that since they have
not held up to their end of the agreement, that the relationship is terminated.
Also be sure to give referrals. I always make sure that I give names
and numbers to DEM's, CPM's, CNM's and OB's. This covers some pretty
good ground. Here is a sample of something I might send IF I was
going to give her ONE MORE CHANCE, which I doubt I would at this point.
I as a midwife believe that prenatal care is an important part of a
healthy pregnancy and happy, successful birth experience. Since first
meeting you we have only had one prenatal visit which is not adequate for
establishing a midwife-client relationship. If I do not hear from
you in the next week, I will assume that you have sought care elsewhere.
If however you do wish to continue care with me, the following will
be necessary.
A physician may terminate his or her relationship with a patient for
any reason including failure to follow physician orders which leads the
physicians to believe that this relationship should not continue.
Therefore, we are enclosing your records and advising you to seek alternative
care. We will, of course, be available to you if an emergency arises and
emergency care remains available through the hospital emergency department.
We will terminate any and all further treatment and/or care of you as of
<date>.
Sincerely,
She is showing great irresponsibility and you will bear the brunt of
ANYTHING that goes wrong. Send her a certified, return receipt requested
letter of release. Include in the letter several alternative caregivers
( doctors in the area, county hospital clinics, etc.) and let her know
you WILL NOT attend her birth. If she calls you in labor, remind
her of your letter and call 911 to go to her house. This will keep
you from being accused of abandonment. These cases are NOT WORTH
IT!!
Documentation
Do's and Don't's - an online CEU course.
Charting
from Midwifery Today's E-News
Great chapter about Labour
Admission and Partogram (Hlth1583) from the British Columbia Reproductive
Care Program.
Documentation
about Shoulder Dystocia is a good case in point lesson about charting.
For the labor/delivery records: I want to know what position the
client is in and where she is at all times on the chart. I want the
chart to tell you the exact story of the birth and I do want to know what
heart tones are q 15-20 minutes during most of active labor and q 5 minutes
during 2nd stage. There is also always a heart tone check after ROM
unless baby follows the water out.
A: Send a ‘friendly’ letter TIAing whomever to ‘cease and desist’ from
making any further libelous/slanderous comments directed toward your professional
entity?
The State vs. Midwives:
A Battle for Body and Soul by Carolyne Pion
California Law - Midwife Payment Through Preferred
Provider
Religious Practitioners
Informed Consent
Court Ordered Medical Treatments And Legal Penalties For Potentially Harmful
Behavior By Pregnant Women:
(1) Judicial intervention is inappropriate when a woman has made an informed
refusal of a medical treatment designed to benefit her fetus. If an exceptional
circumstance could be found in which a medical treatment poses an insignificant
or no health risk to the woman, entails a minimal invasion of her bodily
integrity, and would clearly prevent substantial and irreversible harm
to her fetus, it might be appropriate for a physician to seek judicial
intervention. However, the fundamental principle against compelled medical
procedures should control in all cases which do not present such exceptional
circumstances.
Here are 3 "Special Circumstances" informed consent documents for home-based
care and/or refusal of customary obstetrical protocols for VBAC, Twins,
Macrosomia and her
general page on Informed Consent
Blanket consents (I consent to everything) and blanket releases
(I release everyone from liability) are traditionally disregarded by the
courts. They may be seen as an effort to misinform or deceive the client.
Jensen & Bobak, Maternity & Gynecologic Care, 5th Ed,
page 77.
Client's refusal should be carefully documented and thereafter
respected.
This is one of my favorite topics, it always generates excitement when
couples learn that they can refuse a treatment. I do, however, tell them
that flat out refusal and invocation of these legal rights by threat to
the medical staff is a powerful weapon best used only in extreme cases.
You catch more bees with honey than vinegar!
Hospitals Ignore Informed Consent, Override Parents' Choices or Report
Parents
You have the right to go to the nursery and pick up your baby and
walk out of the hospital.
Lack of Informed Consent
[July 20, 2001 at Memorial Hospital in Jacksonville, FL. OB:
Neil Sager; Lawyer: Harry Shorstein, state attorney for Duval County.]
Non-Medical Forms (Confirmation of Appointment/Pregnancy/Return
To Work/Work Restrictions)
We used to just hand write this out, on Rx pads, but this is SO much more
time-efficient, and looks more official.
{used a lot for students missing class, women missing work}
Birthing Rights
See also: Homebirth Advocacy
Absolute Right to Homebirth in the UK
In the UK, it is written in our Midwives Rules and in law that we MUST
attend women in birth - wherever that be, and however suitable for home
birth. GPs do not have the same statutory obligation.
Lawsuits and Complaints
Cesarean Lawsuit Won by Patient
June 17, 1993 Wall Street Journal
Don't you realize that all of us live in the daily fear of
getting sued or arrested for just trying to do a good job?
It bothers me to hear about any midwife having legal problems.
I suggest that you look within and relax and be thankful that
you have a baby to love and nurture (you don't write much about that) and
redirect your passion.
This sounds like a rather sweeping assertion that anybody who survives
a birth with a live baby should have no complaints. Yes, it could have
been worse, but it could also have been a whole lot better.
Any attack on ANY midwife is an attack against ALL of us and
we cannot pass judgment on her actions as we WERE NOT THERE.
I agree that we cannot pass judgment on a particular case about which we
do not know the facts.
Comment on Ethics from an OB
CLIA and Waived Tests
Physician Backup
In the whole scheme of things, having me out there doing homebirths seems
like the lesser of the evils, so they haven't shown any direct opposition
to what I'm doing. Of course, they absolutely will not condone or support
what I'm doing, either. So I decided that I would approach them with the
fact that if I'm doing homebirths safely, they WILL invariably seem some
transfers and consultations, and to make things as easy as possible for
them, what were their preferences as to how I should go about that? I spelled
out options in writing, they checked off what they wanted, and bingo, I
have consultative arrangements. I haven't needed a lot of physician input
into my practice in the last couple of years, but when I have, they have
been pretty good with me and respectful to my clients.
State-by-State Supervision/Collaboration Issues
Homebirth Backup Physician Useless in Emergency
Physician Harassment
Hospital Privileges
Malpractice Insurance
Endorsed by Unisource Insurance Company
Call or Write Today
Dean Insurance Agency, Inc.
Ann A. Geisler, CPCU
PO Box 3268
Orlando, Florida 32802
800-721-3326
About Being Investigated
Legal Strategies
Strategy for Fighting Charges
I wrote a letter to the BRN and enclosed a press release and the addresses
of 200 radio stations, newspapers and television stations that I was sending
this release out to. Just to inform them that it was going out on the eve
of my final hearing.
Specific Country/State/Personal Situations
Virginia Birthing Freedom
Editorial Comment by Ina May Gaskin (1994) about the arrests
of Lynn Amin, CNM, Beverley Thorpe, CNM, and Lorri Walker, RNP for their
work at their Natural Birthing Services birth center in Southern
California.
Midwifery Legal (in Michigan?) - Not the Practice of Medicine
Because of an attorney general's decision in 1939 that midwifery was not
the practice of medicine, midwifery is still legal to practice here.
Records Release Forms
Release from Care
[Physician's name]
Letter for Release of Care
Sometimes you have clients who mysteriously disappear, cancel or miss appointments,
don't return calls, etc.
I hope that your pregnancy is going smoothly and wish you the best of luck
with whomever you choose for your care.
Dear Ex-Client:
<provider>
Charting
Miscellaneous Legal
Malicious Gossip
Q: What do I do about some other midwives spreading untrue rumors about
my practice?
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