1. Miller, Lisa A. CNM, JD

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I enjoy a cup of fresh brewed tea and like to make a pot when I have to sit down and think about an issue or a concern. Try solving this little problem I sometimes use in my classes.


A teapot and tea strainer together cost $31; the teapot costs $30 more than the tea strainer. What is the cost of each item if purchased separately? The initial answer most folks want to give is that the teapot costs $30 and the tea strainer costs $1, but that cannot be correct, because then the teapot would only cost $29 more than the tea strainer. Many people become so frustrated and stumped trying to work out the answer that they simply give up. But I encourage you to work on this problem until you get the correct answer, because it may improve your logical thinking and problem-solving abilities. And don't fret, I will provide the answer at the end of the column.


Contrary to what many of us believe, logical thinking is not innate to human beings, and any cognitive psychologist can regale you with stories of the irrational decisions made by very smart people. This brings me to something I realized over a cup of tea: the fact that law school actually made me a better midwife. Prior to midwifery school, I worked as a labor and delivery staff nurse, then a night charge nurse at a level III academic center. Finally, just before going to my midwifery program, I established the second nurse-based maternal transport team in Illinois, again, working in high-risk obstetrics at an academic medical center. These experiences gave me an incredible knowledge base in the management of high-risk pregnancies (we were using Swan-Ganz catheters to monitor preeclamptic patients at that time) but provided a skewed and limited worldview regarding normal, uncomplicated birth. Critical thinking and logic per se were not topics covered in either nursing or midwifery school, and when I returned to Chicago to practice midwifery at Cook County Hospital (at the time one of the highest volume obstetric units in the state), I truly believed that it was unacceptable to have a woman labor without an intravenous catheter. I also thought that every birth had to be preceded by coached pushing efforts while someone screamed the laboring women a count of 10 at least 3 times with each contraction. Midwifery school had not been able to change what I absolutely knew from my prior nursing experience. That was in 1982 and the literature was just beginning to reflect the evidence against these practices. But I was having none of it. "Evidence-shemivdence" I thought to myself and proceeded to do things as I always had seen them done and truly believed was best for the laboring woman.


This status quo bias continued until I went to law school, where I learned the value of examining and considering all sides of an issue, where I was taught about metacognition (the concept of thinking about thinking) long before it was defined anywhere in healthcare. In other words, law school made me a better clinician, because it taught me to think critically and logically, to slow down and question my responses and assumptions, and to recognize the difference between dogma and data. Now I am certainly not suggesting all clinicians go to law school, but I do think it is time for us to take a more evidence-based approach to perinatal care and be willing to challenge and question practices and assumptions even if they are widespread and long held. And misinformation, myths, and misbeliefs extend beyond hands-on patient care and clinical decision making.


I do a great deal of myth busting in my classes, one of my favorites, very strongly held and widely believed, is the idea that if something wasn't charted it wasn't done. Not only does this defy common sense (do you chart every action in a patient's room, such as emptying garbage can?) but also has no legal basis. There is no corresponding rule of evidence, no statute, no case law that makes this old adage true, yet nurses and doctors fall victim to this myth on a regular basis. If you are involved in litigation, your defense attorney will review with you the different ways you can offer evidence regarding your care, which, in addition to the medical record, includes your recollections and your customary or usual practice. I do recognize the significance of documentation and I am not discounting the importance of a clear, concise medical record, but I would really like to help clinicians shift their focus. I've got some harsh news-there are no magic words to chart that will somehow protect you from liability. The only way to avoid liability is to avoid being involved in a poor outcome, and that is not always possible. The question we should all be asking in every clinical situation is not "what do I chart?" but rather "what should I do?" because if you do the right thing you will be more likely to have a safe outcome, and much less likely to have your charting come into question later. In addition, consistently following a logical, evidence-based approach to patient care will allow you to articulate what you did, and how you thought and problem-solved with your team, which will help you defend your care, should the need arise, even in situations where your documentation may be lacking some detail.


Now, time for the answer to our logic problem, the cost of the teapot is $30.50 and the tea strainer costs $0.50. Most folks take a while to figure this out, because they are looking for whole number answers, which is how the question is worded. So our not-so-logical brains take a while to consider the use of fractions in solving the problem, and some of us will get frustrated and give up completely. But practicing logic and critical thinking on a regular basis improves our skill and helps "exercise" our brains, improving our problem-solving ability in all aspects of our life. The practice of logical thinking is therefore no game but is crucial to clinical practice, emergency response, and patient safety. So let's start thinking-slowly, logically, and critically-about how we practice, what we know versus what we have been told, and how we draft our policies and protocols. Because something tells me that we could all benefit from this cup of tea.


-Lisa A. Miller, CNM, JD President Perinatal Risk Management and Education Services, Portland, Oregon