Punches and knocks to the physicians: choosing wisely or self protection?

Ugo Indraccolo1

1Complex Operative Unit of Obstetrics and Gynecology, “Alto Tevere” hospital of Città di Castello (PG), ASL 1 Umbria, Italy.

Pervenuto il 26 giugno 2016. Accettato senza richiesta di revisioni il 25 luglio 2016.

Summary. A case of a normal delivery in which the obstetrician has been beaten and insulted without any reason by the patient’ husband is reported. Patient’ husband followed his personal, wrong, perspectives about the labour and delivery. As patients pretend from physicians unnecessary exams and procures irrespective from physicians’ suggestions, the culprits of our failure in not following the “choosing wisely” are the patients.

Key words. Cesarean section, choosing wisely, litigation.

Pugni e botte ai medici: “choosing wisely” o protezione di sé?

Riassunto. Si riporta un caso in cui l’ostetrico è stato picchiato e insultato dal marito di una paziente, senza alcuna ragione. Il marito della paziente aveva seguito dei personali, errati, convincimenti a proposito del travaglio e del parto. Siccome i pazienti pretendono esami e procedure inutili ignorando i suggerimenti dei medici, colpevoli del nostro fallimento nel non seguire lo “choosing wisely” sono i pazienti.

Parole chiave. “Choosing wisely”, denunce, taglio cesareo.

In recent years, the “choosing wisely” campaign has been started to avoid unnecessary examinations, treatments and procedures on the patients1. As acknowledged by readers, in Italy this campaign is called “slow medicine”2.

Recently, I read with interest a perspective about the “illusion of the control” in relationship to the “choosing wisely” on the NEJM3. To attribute positive results to unnecessary interventions is incepted in the humans mind, because the so called “illusion of the control”3. The “illusion of the control” might explain at least in part the failure of the choosing wisely.

Readers and Colleagues should know, however, that some unnecessary interventions were asked by patients to the physicians4, for satisfying patients’ own perspectives and expectations, even if patients are fully informed that unnecessary interventions could be dangerous and expensive.

The “choosing wisely” campaign in Italy has suggested to avoid two procedures that lead to increase Cesarean sections rate5. Those procedures are the continuous cardiotocography in low-risk laboring pregnants and the labor induction before 39 weeks6. Cesarean sections rate in Italy is high, and the maternal mortality due to the Cesareans is the same than other developed Countries. Briefly, when I counsel a patient about risks of a Cesarean, I disclose her that I would be able to kill her by choosing to perform a Cesarean without indications for her own request. Despite such a tremendous counsel, patients feel appropriate to perform a Cesarean, and poorly evaluate me if I do not perform them the Cesareans7. Remarkably, even lawyers and some obstetricians feel to be unappropriated to do not perform a Cesarean section on maternal request7. Therefore, cultural perspectives of patients and other stakeholders involved in the birth process work against my choosing wisely, fighting with my obstetrical caring. The term “fighting” should be used in light of what sometimes happens in Italy during labor and delivery. Specifically, I want to share with readers my bad experience about a case of a fully normal delivery.

A full term, 0 para, healthy pregnant woman underwent labour induction for being at the 41 weeks and 3 days of gestation. She became laboring in the night, and she delivered in early morning a healthy 3900g baby without complications. I was on duty during the night, and I cared her along with midwife to increase the support during labor, because my hospital did not provide the labor analgesia. I expended myself all the night with her and her husband, thereby obtaining the spontaneous vaginal delivery and avoiding a Cesarean. Immediately afterbirth, the baby seemed to do not breath and cry. Therefore, I provided stimulations, oxygen and warm to the baby, while patient’ husband started to beat my head with punches and knocks, and midwife tried to block him.

As already stated, the baby was fine within the first minute from birth. I had not performed anything of extraordinary to the baby. Many babies do not breath immediately afterbirth but they are not compromised. In the succeeding hours, despite I would be came back home after my on-duty, very hard, ship, I tried to explain to the patient and patient’ husband that many babies do not breath immediately afterbirth, and that this is part of the normal process of birth. I received insults and reviles by the patient’ husband. I asked him why. He answered that a Cesarean section had to be done and I had not to make him angry.

The day after the punches, I disclosed the fact to the head of my department, asking him what I had to do. He was many years older than me. He smiled. He sad me that litigation was inadvisable, because the judge could be favorable to the patient’ husband because the baby had not immediately breath. I commented that the baby was fine, the labor and birth were normal and that my care had been correct. I choose wisely. He fully agreed with me. However, he answered that physicians were not highly evaluated by current cultural perspectives. Cultural perspectives could be able to direct the opinion of the judges against physicians. He was right. Even St-Amand, in Canada, described his medico-legal nightmare also reporting the cultural perspectives of his own town, concluding that “even if you win you can still lose”8.

Interestingly, by sharing my experience with other Italian obstetricians, I found similar bad experiences: insults and threats are common, while a Colleague from the south of Italy also disclosed me he suspected to be followed by mafia after a delivery. Is it true? If yes, it is possible?

Summarizing, psychological believing lead patients to a priori consider the chooses of the physicians as errors and malpractice, asking to physicians unnecessary interventions, and hating the physicians if such interventions were not conceded. Therefore, some litigations are the only legal way to destroy the physicians for the patients and their familiars. This is what is happening in Italy, where litigations for presumed medical malpractice are increasing. However, when litigations fails, someone can think to injury-us in other illegal way.

In this scenario, our choices can be forced by self protection rather than by the “illusion of control”3, leading to the failure of the “choosing wisely”. We cannot be good physicians because the culprits of our failure are the patients.

Conflict of interests: the author declares that there are no conflicts of interest.


1. choosingwisely.org [Internet]. Philadelphia: ABIM Foundation [©2016. Cited 2016 Jun 26]. Available from http://www.choosingwisely.org/

2. Bonaldi A, Vernero S. [Italy’s Slow Medicine: a new paradigm in medicine]. Recenti Prog Med 2015; 106: 85-91.

3. Casarett D. The science of choosing wisely-overcoming the therapeutic illusion. NEJM 2016; 374: 1203-5.

4. choosingwisely.org [Internet]. Philadelphia: ABIM Foundation [©2016. Cited 2016 Jun 26]. Available from http://www.choosingwisely.org/wp-content/uploads/2015/04/Final-Choosing-Wisely-Survey-Report.pdf

5. slowmedicine.it [Internet]. Torino: Slow Medicine [2016. Cited 2016 Jun 26].

6. slowmedicine.it [Internet]. Torino: Slow Medicine [2016. Cited 2016 Jun 26]. Available from www.slowmedicine.it/pdf/Pratiche/110 pratiche.pdf

7. Indraccolo U, Scutiero G, Matteo M, et al. Cesarean section on maternal request: should it be formally prohibited in Italy? Ann Ist Super Sanita 2015; 51: 162-6.

8. St-Amand J. Medicolegal nightmare: a tragic case, a needless trial. CMAJ 1993; 148: 806-9.