The Recovery Room 011: Cesareans, Foreign Medical Grads

Segment 1: Cesareans
Guest: Dr. Bill Grobman, co-author of revised VBAC ("vaginal birth after cesarean") guidelines for College of Obstetricians and Gynecologists

Since 1970, the cesarean delivery rate in the U.S. has jumped from 5% to more than 30%. (The rate recommended by the World Health Organization is 15%.) A lot of factors have contributed to the increase: more women are giving birth at an advanced age and more are having multiple births - twins and triplets - some as a result of fertility treatments. Doctors' fears of litigation has contributed, as well; as could the fact that cesareans pay doctors more - on average, almost twice as more - as a vaginal birth.

Another factor: electronic fetal monitoring. Introduced in the 70s, it's now become standard in most births. Changes in the baby's heart rate - a possible sign of too little oxygen - will often result in a c-section; but there's little proof that the test actually saves lives.

And despite the fact that most women who've had a c-section can safely give birth vaginally, less than 10% are having VBACs - or "vaginal birth after cesarean." VBAC rates have fluctuated over the years largely in response to shifting guidelines. A 1999 revision stated that hospitals had to have surgery and anesthesia teams "immediately available" - that is, on site - in the case of a woman requesting a VBAC. The costs of this recommendation lead many hospitals - especially smaller and rural hospitals - to ban the practice.

Just last month, the college of Obstetricians & Gynecologists revised its guidelines again. The new guidelines reaffirm the safety of VBAC for most women. But they also retain the "immediately available" language regarding emergency care. A recommendation that women be allowed to accept "increased levels of risk" has also been added. The question remains whether this will have the hoped-for outcome - that is, an increase in VBACs and a decrease in the overall cesarean numbers.

Segment 2: Foreign Medical Graduates
Guest: James Hallock, former president of the Educational Commission for Foreign Medical Graduates

One of the biggest problems facing the health care industry today is a shortage of primary care physicians. As US med school grads choose specialization over general medicine, foreign medical graduates are coming to the US for residency programs and many are sticking around and helping to fill primary care vacancies.

By a wide margin, the largest number of foreign medical graduates have come from India, but significant numbers have also come from Pakistan, the Philippines, China, Egypt, and the Dominican Republic. But how comparable is medical education in these countries? And how equipped are these international doctors to care for sick Americans?

Since 1956, the Educational Commission for Foreign Medical Graduates has evaluated and certified foreign medical grads for U.S. residency programs. In 2008, the commission issued over 10,000 certificates. If the commission's previous statistics apply, about 7,000 will end up practicing medicine here in the States.