🏥 When Good Care Becomes a Liability: A Rigorous Defense of Evidence-Based Practice

There’s a quiet war happening in hospital hallways—not just over reproductive rights or medical misinformation, but over something more insidious: how evidence-based medicine is devalued when it threatens administrative efficiency.

I’m not talking about politics. I’m talking about practice standards, liability reduction, and what it means when a hospital tells a physician they’re “billing too many hours” for providing care that directly follows CRICO and ACOG guidelines.

Strip away the language, and here’s what they’re really objecting to:

• Time spent practicing real medicine.

• Time spent reducing liability.

• Time spent following national standards that happen to be… inconvenient.

• Time monitoring Category II fetal heart rate tracings, which require “reevaluation and continued surveillance”

• Time performing intrauterine resuscitation, including repositioning, oxygen administration, and fluid management

• Time honoring ACOG’s labor management guidelines, which explicitly state that slow but progressive labor is not an indication for cesarean

• Time choosing evidence over expedience, even when that evidence takes hours to unfold

So what are they really saying?

They’re saying: Don’t follow the guidelines that protect your patient—and reduce your liability.

They’re saying: Don’t wait the four hours ACOG recommends before diagnosing active phase arrest.

They’re saying: Your commitment to clinical integrity is bad for business.

And I take that not just professionally—but personally.

🩺 The Medicine I Was Trained To Practice

I trained in a culture where liability was mitigated through clinical rigor, not corner-cutting.

Where Category II tracings prompted real-time bedside assessment—because CRICO is clear: fetal status is dynamic and must be continuously reassessed.

I’ve spent hours working through protocols that aren't flashy or dramatic—but save lives:

Stopping oxytocin. Repositioning. Giving fluids. Coaching through second stage.

I’ve performed External Cephalic Versions for breech babies many providers would automatically send to the OR—because ACOG supports ECV as a way to safely reduce cesarean rates.

Not because I’m risk-averse.

Because I understand the difference between clinical vigilance and anxiety.

And because I know that following established guidelines reduces liability, improves outcomes, and preserves reproductive autonomy.

⏱️ Evidence-Based Time Is Not a Billing Problem

When ACOG states that “a slow but progressive active phase of labor… should not be an indication for cesarean,” that’s not inefficiency. That’s safety. That’s respect for physiologic labor. That’s evidence.

When CRICO says that “the attending should personally evaluate the patient and document no later than two hours into second stage, and every hour thereafter,” that’s not excessive oversight. That’s the standard of care.

Let’s also remember the data:

Extending oxytocin from 2 to 4+ hours allows the majority of patients to achieve vaginal delivery—with no increase in neonatal harm.

For first-time moms, 8 hours of augmentation reduced C-section rates from 35.5 % to 18 %.

This is not about overtime. This is about outcomes.

💪 I’m Not Anxious. I’m Adherent.

Let’s cut through the administrative gaslighting.

I’m not an anxious provider who over-manages out of fear.

I don’t stay at the bedside because I’m unsure.

And I’m certainly not staying up 20+ hours to make a few extra dollars.

The idea that prolonged clinical vigilance is financially motivated is not just wrong—it’s insulting.

The math doesn’t work. The personal cost is enormous.

You lose sleep, lose focus, lose productivity for days.

Your body breaks down. Your lifespan shortens.

When I stay, it’s because leaving would compromise care.

Because CRICO requires continuous monitoring for oxytocin use, second stage abnormalities, and non-reassuring fetal assessments.

Because ACOG guidelines don’t reward speed—they reward safety.

There is a critical difference between clinical anxiety and evidence-based vigilance. Between defensive medicine and defensible medicine.

⚖️ The Professional and Legal Reality

I run my own practice. That means I see the economics—and the consequences—of every decision.

When I follow ACOG and CRICO to the letter, I’m not “being extra.”

I’m:

• Reducing malpractice exposure

• Optimizing outcomes

• Maintaining my reputation

• Protecting future pregnancies

• Preserving my own career longevity

And I’m doing it at a loss, not a gain.

No one volunteers for a 24-hour labor management marathon out of greed.

We do it because that’s what the clinical situation demands.

When I document appropriately, I’m not padding a file—I’m protecting the patient, the nurse, the system, and myself. And CRICO makes it plain: “documentation failures are a leading factor in malpractice loss.”

🏚️ The System Is Collapsing Around Us

This would be bad enough if the hospital’s resistance to good care were just about misunderstanding. But it’s not.

It’s happening inside a broader collapse of the very infrastructure meant to support this work.

On July 4, 2025, the One Big Beautiful Bill Act (OBBBA) became law, enacting the largest federal Medicaid cuts in U.S. history—$793 to $911 billion over the next decade. This is the safety net for 41 % of births in America. And it’s being shredded.

The fallout is already here:

• Work requirements starting in 2027 will strip 4.8 million adults, disproportionately women of reproductive age, from Medicaid coverage.

• Redetermination intervals have been halved, booting patients off coverage faster—saving money by denying care.

• Hospital subsidies are evaporating. Limits on provider taxes and payment reductions to Medicare rates will slash another $161 billion in lifeline funding.

• Labor and delivery units are closing at alarming speed. In 2024 alone, 37 obstetric units shut down. Since 2011, the total is now over 260.

• Entire regions are becoming maternity care deserts—35.1 % of U.S. counties now have no birthing facility and no OB provider.

In this financial landscape, obstetrics is treated as a “loss leader.”

Hospitals say the quiet part out loud: It costs too much to deliver babies.

And Medicaid reimbursement often doesn't even cover the cost of prenatal care.

Physicians are leaving the field. Why wouldn’t they? The average medical school graduate owes $205,000. OB/GYN offers $372,000/year, while specialties like neurosurgery, plastic surgery, and interventional cardiology pay $600,000+ with lighter malpractice burdens and fewer nights awake.

Over a career, the earnings gap is more than $2 million.

So let’s return to the accusation: “You billed too many hours.”

What kind of doctor chooses this field, stays up for 20+ hours managing complex labors, and documents everything according to national standards—for money?

You don’t.

You do it because a woman in labor deserves presence.

Because losing OB access means people give birth in ERs—or not in time.

Because Black women still die at 3x the rate of White women.

Because one in three maternal deaths in New Mexico involves car crashes en route to care.

Because some women are traveling two hours or more just to find a bed.

The hospitals complain we stay too long.

Meanwhile, women are dying because no one stayed at all.

🚧 Penalizing Standards Is Systemic Misalignment

When a hospital flags a provider for “too many hours,” despite full adherence to evidence-based guidelines, it reveals a deeper crisis:

• They are incentivizing the wrong things.

• Pressuring shorter observation than ACOG supports.

• Discouraging proper fetal monitoring.

• Pushing for faster delivery, even when it increases risk.

They are penalizing the very practices that protect patients and reduce institutional liability.

This is not just a miscommunication—it’s a dangerous structural failure.

You can’t demand quality metrics and then punish the work required to meet them.

📊 Quality Metrics vs. Quality Care

ACOG, CRICO, The Joint Commission—these bodies exist to set standards. And they’ve made their position clear:

ACOG/SMFM: Extend augmentation to 4+ hours for safe vaginal delivery

The Joint Commission: NTSV C-section rate is a national quality measure

ACOG Clinical Guidelines: Prolonged second stage is defined as >3 hrs nullips, >2 hrs multips—with individualized management encouraged

So when physicians are penalized for following these exact standards, it’s not us who are out of line.

It’s the system.

🔑 This Is About Integrity—Not Efficiency

I will not apologize for:

Staying when a tracing is borderline.

Documenting what CRICO says must be documented.

Avoiding unnecessary surgery.

Following ACOG’s protocol when it demands time and presence

Practicing with integrity, even when it costs me sleep, time, and revenue.

The accusation that extended labor management is financially motivated ignores the realities of both economics and human physiology.

We don’t stay for the money.

We stay despite the toll—because the standard of care demands it.

🔄 Realignment Is the Only Way Forward

The answer is not to degrade our practice to fit flawed administrative expectations.

It’s to realign those expectations with what we know works:

Link compensation to adherence, not just throughput.

Reward documentation that meets legal standards, not punish it as inefficiency.

Treat prolonged labor care as high-skill work, not wasted time/

Recognize that malpractice reduction is an institutional benefit, not an individual luxury.

🚩 Final Word: Good Medicine Shouldn’t Be a Red Flag

If CRICO and ACOG are the standards—and they are—then adhering to them should be seen as a mark of excellence, not excess.

So when you say I billed too many hours, what you’re really saying is:

You stayed too long with that patient.

You watched too closely.

You tried too hard to prevent a cesarean.

You followed the guidelines too carefully.

And to that, I say:

You’re welcome.

She left with her uterus intact.

And I’ll do it again.