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Maternal-Fetal Medcine: Richard Fischer
30 Plays5 months ago
Dr. Richard Fischer is a maternal-fetal medicine specialist at Cooper University Hospital in Camden, NJ. Listen to Richard discuss the experience of being a male OBGYN physician, the work of midwives and doulas, and factors that contribute to complicated pregnancies.
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Transcript
Introduction to The Wound Dresser Podcast with Dr. Richard Fisher
00:00:09
Speaker
You're listening to The Wound Dresser, a podcast that uncovers the human side of healthcare. I'm your host, John Neery.
00:00:21
Speaker
My guest today is Dr. Richard Fisher. Dr. Fisher heads the division of maternal fetal medicine at Cooper University Hospital in Camden, New Jersey. He is also professor of obstetrics and gynecology at Cooper Medical School of Rowan University, teaching both residents and medical students. Dr. Richard Fisher, welcome to the wound dresser. Thank you very much for inviting me.
Role of a Maternal Fetal Medicine Specialist
00:00:42
Speaker
So I know you've been in OBGYN now for a number of years. Can you kind of just explain to our listeners ah what your daily responsibilities are as part of being part of the OBGYN service? Okay. So just ah to qualify, I've been doing this for, I've been in attending for 34 years after my training, but I'm not a typical OBGYN. So OBGYN does four years of, of a residency and then they're qualified to, to practice general OBGYN. So,
00:01:10
Speaker
After my training, I did an additional two years, it's now three years, from maternal fetal medicine, which deals with high risk pregnancies. So I basically had to give up my gynecology ah training to focus mostly on obstetrics and high risk obstetrics.
00:01:24
Speaker
Okay. And what is, I mean, generally the the patient demographic that you're looking at, could you give us like an age range, like patients that you generally see ah throughout the day? Anybody who is of reproductive age, anywhere as young as, you know, 15 sometimes to as old as 50. So anybody who can and may become pregnant.
00:01:45
Speaker
I'm sure it's evolved throughout your career, but ah in terms of there being a lot of ah men in OB-GYN, has that varied throughout your career? Oh, very much so. So when I did my residency, it was a 50-50 split, and currently it's 90 to 95% of women going into the field.
00:02:02
Speaker
So what are the ah the gifts and challenges of kind of being a man in this field? Well, it certainly puts me in the minority. And um my ah standard answer is now I can appreciate what women have had to deal with going through medicine ah for the last 50 years and having to deal in what was traditionally ah a man's profession and having to work twice as hard to be deemed half as good.
00:02:24
Speaker
So, now it's me that has to work extra hard to show that I'm just as good as someone who doesn't have of female reproductive organs. But ultimately, if you can relate to the patients and empathize with their situation, that I think men can be very successful in this field and women um don't hesitate to come to
Challenges and Successes as a Male OBGYN
00:02:45
Speaker
me. But again, my situation is different from a general OBGYN. I'm not doing ah pelvic examinations of doing more ultrasounds and counseling and and talking about the pregnancy rather than doing internal examinations, which many individuals might feel uncomfortable. But there are many male gynecologists whose schedules are as packed as as any female gynecologists. So again, it's it's really just ah the interaction that they have with patients.
00:03:14
Speaker
Do you think in a way it kind of gives you a leg up in terms of if ah you know a patient has a husband or or someone else involved with the family that you can kind of ah relate a little bit better? No, not necessarily. it's it's really I relate more to to my patients who are female, and I don't think at the end of the day it really makes any difference, although you know it's getting into that that that first step. but you know A lot of people say, oh, I prefer to see a female, which I absolutely understand and appreciate, but once I meet them, I think I can you know form that relationship so that it doesn't matter. but
00:03:47
Speaker
I wouldn't say I ever have a leg up. it's It's a leg down and I have to, like I said, work extra hard to prove myself equally as good.
Team Roles in Pregnancy Care
00:03:55
Speaker
Um, I imagine when ah a woman is pregnant, there's kind of like a lot of, you know, medical professionals involved with the care. Um, you know, you, you're saying you're specifically, and you know, maternal fetal medicine, then there's, they might have a gynecologist in the picture. And then on top of that, they probably have an internal medicine physician. And then when you're looking at actually giving birth, you're eventually going to have a pediatrician. So how do you kind of divide up all that labor and, uh, you know, see kind of, kind of divide the parts so everybody can help the patient the best they can.
00:04:24
Speaker
It's a great question. So you're right, many individuals will have an internal medicine or or general practitioner or family medicine physician. um In many cases, the gynecologist can act as the primary care physician for our female patients, so they don't necessarily need to see an internist at the same time, but they might.
00:04:41
Speaker
Once they get pregnant, we prefer that the OBGYN be the primary care physician, that they know not go back to their primary ah GP or family medicine or internal medicine because we have an understanding of pregnancy that the internist might not might not. So we become their primary during ah the pregnancy.
00:05:01
Speaker
um As a maternal fetal medicine specialist, I am trained to deal with medical complications in pregnancy. So again, I feel very comfortable dealing with many of the routine medical complications that can occur. There are specialists that have much greater knowledge like cardiologists,
00:05:20
Speaker
ah sometimes endocrinologists that we will refer to if there's things that we cannot handle. So we will make referrals to other specialists when necessary. And as for the pediatrician, ah we may make some recommendations for pediatricians, but once that baby is born, that baby is under the care of the pediatricians, and we just focus just on on the pregnant and now postpartum patient.
Midwifery and Doulas in Labor Support
00:05:42
Speaker
Okay. And there's a couple other ah you know roles that that have've I've heard a lot about recently, midwives, doulas. I guess we could start with midwives. like What kind of role do they play in that whole team and um and and how are they involved in the care for the patient?
00:05:58
Speaker
So, unfortunately, we don't have a midwife ah midwifery program at Cooper. We had it for a short time, but it didn't it didn't last. I think midwives are great. If I knew that there was going to be an uncomplicated pregnancy, I would wish all my patients to be delivered by midwife. They just have a very naturalistic way of of delivering it, delivering babies, and I think they're wonderful.
00:06:20
Speaker
i What I really appreciate are those practices that had the midwife practice embedded within the obstetrical practice. So if there is a complication, the OBGYN is there to step in to do a caesarean section or an operative vaginal delivery. um So I like it when they work handin hand in hand. if pregnancy is uncomplicated and proceeding normally during labor, I think it's great to have ah midwives do the delivery. As for doulas, this is something that is increasing. um ah They just passed some legislation in New Jersey ah requiring that doulas be allowed in for deliveries, and we are actually actually getting started on on
00:06:58
Speaker
making recommendations for doula programs so that every patient can have a doula in labor because it's been shown to be very comforting for the patients and actually helps to reduce the caesarean section rate.
00:07:11
Speaker
So what what would you say or is the difference in like responsibilities between the midwife and the doula? It sounds like they're both kind of involved at delivery. but Great question. So the midwife is the practitioner who's actually doing the delivery. The doula is a support person for the patient. So they're not making medical decisions, but they are advocating for the patient. So they have experience with with labor. So they can um
00:07:36
Speaker
reiterate what's going on in terms that patients may understand better because we in the medical profession tend to use a lot of medical terms that may not be as well understood. And um they, again, advocate for ah birthing plans or whatever the patient has elected. and It is comforting. um So instead of, you know, if the patient wants, you know, a glass of water or ice chips during labor, instead of making the the partner go out, get it, she can, you know, go out and do things for the patient so um ah the partner can be by the patient's side at all times.
00:08:10
Speaker
So with with all the people that we've mentioned, you know physicians, you could have nurses, you could have family, you could have doulas, you could have midwives, you could have all sorts of people. Does that ever feel like there's it like too many cooks in the kitchen? it's We are in a unique specialty where no other specialty practices in front of such a large audience. And you know you we do surgical procedures, but our patients are awake and we have of you know a support person that's watching the procedure or or by the patient's side as we're doing the the ah procedure.
00:08:40
Speaker
So, um it it is very unique. So, we we want to integrate the family, but we also have to recognize that obstetrics, that things can go ah south very quickly. So, you have to be always prepared to take ah a patient who's uncomplicated, and then they become very complicated. You need to move fast, and sometimes there could be a lot of people in the room that need to be cleared out so we can address the patient's needs.
00:09:04
Speaker
I want to switch gears a little bit and talk about just kind of general trends in OBGYN. I know once again, you said you're in maternal fetal medicine, you deal a lot with um you know more complicated cases. But one of the things you hear about just in general with women delivering is i like declining birth rates that like in some countries, um they're they the governments are literally trying to incentivize people to have babies. I think Japan's one. um Denmark is another I've heard. i don't know but Is that something you've seen a lot of evidence in your own clinical practice that you know there's there's a lower birth rate?
Trends in Birth Rates and Maternal Age
00:09:33
Speaker
ah There has been a trend over the last few years, at least at Cooper Hospital, where there has been reduced – I mean, not a huge ah reduction, but there has been a gradual reduction of ah birth rates. At our peak, we did
00:09:45
Speaker
2,200 or 2,250 deliveries and we're down to 1,850, 1,900. So there has been a decrease and apparently it's it's mirroring what's going on in the South Jersey region and and perhaps nationally, but I don't know those numbers off the top of my head.
00:10:01
Speaker
And with that, are are also the ah the women who are delivering, are they of an older age compared to ah you know previous times? Definitely. People are definitely delaying childbearing until later on. So ah my my joke is 40 is the new 20. So yes, we're seeing a lot of people who are older.
00:10:20
Speaker
um and ah we're We're fine with that. There are some higher risks that go along with that, but as long as patients are aware, um most are successful. So we we're happy taking care of them. Yeah. And a lot of the complications you do see in maternal fetal medicine, is that or do you do you feel like some of them are contributed are related to the women being of older age? Sure. Higher risk of diabetes and hypertension, there's a higher no rate of obesity that's that's occurring. ah So yes, there are Our patients seem to be getting more medically complicated. Plus, with advances in in medicine, many individuals who might have ah died ah before childbearing age from cardiac disease are now surviving and are living through their own pregnancies. So it does ah pose some unique issues for the pregnancy. The the other thing I hear a lot about ah is like you know environmental exposures. like
00:11:14
Speaker
Microplastics are in ah you know affecting fetal health. is that Are those environmental exposures other things that are causing complications during pregnancy? Hard hard to tease out what's what's contributing to to the outcomes, but we know that micro and nanoplastics are all around us and we are what we inhale and what we eat. and so we are There are studies that are showing microplastics are being found in human placentas and in the meconium, which is the first bowel movement of of babies. So it is getting ah across that that compartment to the fetus. So if we're exposed to it, so is the fetus. um Whether or not it's having a tangible impact on outcome, ah hard to measure because there are so many other co-variables that can affect the outcome.
00:12:04
Speaker
Uh, another thing kind of on a different spectrum, a complication that can happen with, with, um, I guess post pregnancy would be postpartum depression. And correct me if I'm wrong. I think you did some, you've done some research before on postpartum depression. Um, how does that, that, uh, you know, the presentation and the treatment for postpartum depression differ from say, like just, um, a typical psychiatric major depression?
00:12:28
Speaker
Well, first of all, let me let me clarify. I tried to do research on it. I came up with the bright idea of prophylaxis starting ah individuals at high risk for postpartum depression on sertraline or Zoloft immediately after delivery to see if it would impact on postpartum depression rates. And after one year, we only had two patients sign up for that. So the study ended up but closing without any conclusions. But in terms of the treatment, it's more about recognizing it and distinguishing it from the postpartum blues, which is common, um and versus depression, which is you know a a condition that can lead to ah serious ah depressive symptoms and ultimately to to suicide in some cases. So it's a question of recognizing it and then getting them right into treatment. But the treatment really
00:13:18
Speaker
doesn't differ that much. um The medications that we use are similar to people who are ah not you know just having had babies and we can start them on medications and route them to ah mental health professionals to to see them ah down the road. Again, as a maternal fetal medicine specialist, it's not something that I deal with on a regular basis because I deal more with the antipartum, the pre pre-delivery and sometimes the the the delivery itself, but once they're delivered, they're managed by the general OB-GYN. So there they're the ones who are actually the frontline people who are who are witnessing this and getting them started on treatment.
00:13:55
Speaker
So would you say that general OB-GYN practitioner, would they be the ones to prescribe, say, antidepressants or things like that? Or is it generally like an automatic referral out to a psychiatrist? ah Either one is acceptable. The problem is, is in the pipeline, there's, you know, it's a long lag time to see a psychiatrist or a mental health professional. So sometimes it's reasonable to get them started on medication and then make the referral. So because it takes, you know, up to two weeks with these medications to kick in.
00:14:23
Speaker
And do you even see like some patients who have, you know, these mental health issues like early on or middle of the pregnancy, it it doesn't it doesn't ah wait till to present till afterwards or or not really? I personally don't see it a great deal. um It's possible that if the OBGYN encounters it, they make a referral to psychiatry. And so I would never know about it. But I would say that's relatively uncommon. ah We certainly see a lot of people who have depression outside of pregnancy who become pregnant.
00:14:52
Speaker
And one of my big bugaboos is is either the patients or their mental health providers say, oh, you're pregnant, you have to stop your medications, which is ah not a great idea because we know that the risk of untreated depression ah is much greater than the risk of taking the medication. So untreated depression can lead to smaller babies, earlier delivery, delivery preeclampsia, problems with breastfeeding, and even depression in their new in their offspring. So it's important to have good both physical and mental health during the pregnancy. So I advocate that they continue their medication. Again, some women say, well, and I'm nervous, I'll take half the amount of medication.
00:15:29
Speaker
And that is very counterproductive because you're still exposing the baby, but then you're taking a suboptimal dosage. So I say you need to take your medication and in fact, remember that during the pregnancy, the the blood volume increases by about 50%. So it effectively dilutes the concentration of any medication that you take. So instead of going down on your antidepressants, you may need to go up on it to maintain the same same serum concentration.
00:15:55
Speaker
Now, if you're like encountering a woman with a complicated pregnancy, um is how does the discussion start of like whether they want to you know end the pregnancy,
Discussing Pregnancy Termination Sensitively
00:16:06
Speaker
continue on the pregnancy? does that How does that happen in the clinical setting? So for me, it doesn't happen so much for the ah normal pregnancy because I would not necessarily have that discussion with the patient unless the patient brought it up. But certainly, when I see a fetus with an anomaly,
00:16:22
Speaker
or a genetic complic ah abnormality, I do ah make them aware of the availability of ah pregnancy termination, which fortunately is still legal in New Jersey. um And I make them aware of the options um and give them the opportunity to make a decision and whatever they decide, we support 100%.
00:16:41
Speaker
Is that like a really hard topic to address like in the clinical setting because you you don't know necessarily what the the patient's values are, what their beliefs are, and how they're going to react to ah so ah discussing that topic? Yeah, that's that's a good point. And you know having done this for 34 years, I think I have the wording down in such a way that I certainly, we never should suggest that a patient should terminate their pregnancy. That's absolutely up to the patient's you know ah decision making.
00:17:09
Speaker
um but is also my job to always offer it. And I let them know that this is an available option, not that I'm recommending it or not recommending it, but that this is a legal option for pregnancy that's both normal or abnormal. And I give them the details so as as they ask for more information. So it's it's not uncomfortable for me to raise it. And it's really been a very rare patient who has taken offense at my bringing up the topic. um Most people appreciate knowing that this is an option for them.
00:17:39
Speaker
What are what are like kind of like the main details that you make sure to pass along to them about that? ah Just that it's legal in New Jersey and um I make them aware of where it can be done, um either in the hospital setting or in an outpatient setting and what their limits are because even though there's actually actually no statutes in and the the law New Jersey legislature that says when you can or cannot terminate a pregnancy, ah at for example, at Cooper Hospital, We don't perform terminations after 24 weeks, but there are outpatient facilities in New Jersey that will perform in up to 27 weeks, and out of state, um there are are places we will we'll do it even after that period of time.
00:18:22
Speaker
Is that ever, is that an all like a divisive issue like amongst the profession? Like do you do you feel like people depending like regionally, like where they're located in the country or or what their, like I said, once again, values and beliefs are that that divides people within the OBGYN profession?
00:18:38
Speaker
not amongst the colleagues that I work with. I think people tend to flock to like-minded colleagues, and um so there's no division amongst our um our immediate colleagues. Now, there may be a trainee or a nurse who doesn't want to participate in in an abortion procedure,
00:18:59
Speaker
and they're under no obligation to participate, um ah but we have plenty of providers who are pro-choice and are willing to provide the service. So yes, certainly nationally, it is a divisive issue, but fortunately, in the setting in which I work, it's not an issue.
00:19:16
Speaker
I'm sure you encounter a lot of patients ah you know who are either young or for for whatever reason might not be ready for parenthood. What can you as a maternal and fetal medicine physician do to to kind of i put them in a better position to to to start parenthood?
00:19:33
Speaker
So a lot of this begins in in the prenatal care setting with their their primary OBGYN or the clinic that they go to. So if it's financial, we try to direct them to places for financial aid. Fortunately, if you are pregnant and you are a US citizen, you have Medicaid coverage during a pregnancy. So there should be no barrier to coming in and being seen by an OBGYN provider um for People who are socially not ready, um then there would be a discussion about pregnancy termination. But again, that wouldn't come to me as much it would come to the general OB-GYN. But there is social service sub ah ah ah specialists who can deal with issues with, you know, with housing, if that's an issue. ah If there's drug use, we we have a very strong addiction medicine program at Cooper. So they can have conversations with them. um and And we try to support them as much as possible. And if they decide to to not continue the pregnancy, then we ah make referrals to places where that can be accomplished. um Is that like just a difficult feeling as a physician, being like unable to potentially help like ah like a person and ah and a family?
00:20:51
Speaker
I guess, for for for me, one of my big missions is to make sure that every pregnancy is is planned and and desired. That's always the ideal. um If it's not planned and still desired, great. We support them. If it's undesired, then we help help them end the pregnancy. But i I'm frustrated by the lack of availability of of immediate ah effective contraception.
00:21:17
Speaker
um It can be expensive for some people there are barriers to getting it. And so I'm a big proponent of birth control. And so I have that discussion with my patients ah when I'm doing my ultrasounds with them asking what their childbearing plans are. um And if they want 10 kids, then they should have 10 kids. And if they just want one, then I talk about methods of birth control, both reversible and irreversible, and talk about the options while they're still pregnant so they can make a plan for once this baby's born getting on effective birth control so they can they can space out their pregnancies to to when they want to have them. um Looking forward, do you see any ah important things happening in terms of the the future research in your field?
Research Needs in Preterm Labor
00:22:02
Speaker
Oh, yeah I mean there's so much research that is being done that that needs to be done. ah you know Preterm labor is one of our biggest issues um and it seems to be hovering at 10 to 12% and we really haven't made big inroads in reducing the rate of of preterm birth.
00:22:21
Speaker
And we don't have a great understanding. We don't understand what what initiates term labor, much less pre-term labor, and um or what causes someone to break their water bag repeatedly, or or people who've had term deliveries that all of a sudden break their water bag at 24 weeks. So that's about six months.
00:22:41
Speaker
um And so, yeah, there's a lot of research that needs to be done in terms of management or prevention of preterm labor. There have been a lot of strategies, but not long-term. And then, of course, whatever we can do to optimize ah ah patients' physical health prior to the pregnancy, of weight control, blood pressure control, ah blood sugar control, anything that can be done prior to the pregnancy is much ah much more ideal than waiting until they're pregnant and then trying to control it after the fact. And all these things like cigarettes, smoking, drug use, hypertension, diabetes are all things that can impact on the rates of miscarriages and and preterm birth and and
00:23:23
Speaker
perinatal mortality. So if we can make inroads that way, I think that would would go a long way towards improving perinatal health.
Engagement in the Field Beyond Medicine
00:23:31
Speaker
you know You've already had a busy day today. Thank you so much for for coming in and and taking your time to speak with me. But like ah you know your per your your specific field definitely has a reputation for being rigorous and and challenging. How do you kind of i you know keep yourself engaged and optimistic throughout the whole process?
00:23:48
Speaker
It's a great question. ah It is the second leading cause, specialty for for burnout after emergency medicine. um And I understand it. It it is high-paced. We have to go from zero to 60 very quickly. We have to be efficient and and and thoughtful and when we have obstetrical emergencies. And there's always that demically sort of malpractice suits that hangs over our head if something goes bad.
00:24:15
Speaker
And again, it's all about establishing good relationships with patients and making sure they understand that that we're not God-like figures that's going to guarantee an outcome, that we're going to do our best. We're going to partner with the patients to try to get the best outcome possible um and not make any promises because obstetrics, you can't promise.
00:24:33
Speaker
as And it's it's every day i go to work and i don't know what i'm going to face and every week i feel like i see something that i've never seen before so been doing this thirty four years actually next week will be thirty five years and i have no intention of stopping until i master the damn specialty in which means i'm probably never gonna retire until i have my stroke.
00:24:53
Speaker
um But outside of of medicine, there are things that do keep me fresh, that that that keep me coming back every day. I teach medical students, which I really enjoy, teaching the residents and junior faculty. I do do some clinical research to keep myself sharp, which I i really enjoy when I i have a ah ah ah paper that is published. And then outside of of Outside of work, i I keep very active physically. I play a lot of tennis three times a week. I bike when I can't play tennis. I spend time with my family, my wife, and my children and grandchildren. I'm currently yeah ah in a theatrical performance that that's in a month, so I have this big straggly beard and I'm in rehearsals three days a week and I'm still trying to bike just before the rehearsals or first thing in the morning. I'm trying to squeeze everything in, but I really enjoy and it keeps me fresh.
00:25:46
Speaker
And you know I'm going to keep going until I can't anymore. Busy guy. Thanks for thanks for taking the time. but So we're going to finish up with a lightning round. It's a series of fast-paced questions that tell us more about you. OK. So what's the best part of about practicing in Camden? Feeling that I'm making a difference to a population that really needs it. What's your favorite summertime activity? Playing tennis.
00:26:14
Speaker
What is the who is the most famous person you've ever met? Who? You could say me. no No, not gonna be you. um um George McGovern, who ran for president back in 1972, I got got his autograph, met Simon and Garfunkel. um um My wife shook Obama's hand when he was campaigning, which was a big thrill for her. um ah My biggest ah ah hero is my dad. And ah so I got to spend many years with him. Who's your favorite author?
00:26:50
Speaker
I don't have one favorite author. um Oh, gosh. ah camerama calvin ah I can't remember his last name. He wrote a book called Tipper Isn't Going Out, and it's one of my favorite books. um I can't come up with any other authors off the top of my head. i've I don't really read a lot of books. I read a lot of journals to keep up, so I'm not up on on the best literature.
00:27:20
Speaker
And lastly, what is one change you'd like to see in healthcare? care Just one. Just one. I'd like to see better access to care um so that every patient has the same ah ah same option of of seeing a practitioner and having high-level medical care, I would say. All right, Dr. Richard Fisher, thanks so much for joining the show. Thank you. I enjoyed it.
00:27:57
Speaker
Thanks for listening to The Wound Dresser. Until next time, I'm your host John Neery. Be well.