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The challenges physician leaders confront today call to mind Odysseus' challenge to steer his fragile ship successfully between Scylla and Charybdis. The modern Scylla takes the form of ever-increasing pressures to provide more resources for professional liability, compliance, patient satisfaction, central administration, and a host of other demands. The modern Charybdis takes the form of ever-increasing pressures to procure resources when fewer are available and competition is continuously increasing the need for resources, including managed care, hospital administration, payers, employers, patients who are uninsured or underinsured, research funding, and philanthropy. This publication provides physician leaders with guidance for identifying and managing common leadership challenges on the basis of the professional responsibility model of physician leadership. This model is based on Plato's concept of leadership as a life of service and the professional medical ethics of Drs John Gregory and Thomas Percival. Four professional virtues should guide physician leaders: self-effacement, self-sacrifice, compassion, and integrity. These professional virtues direct physician leaders to treat colleagues as ends in themselves, to provide justice-based resource management, to use power constrained by medical professionalism, and to prevent and respond effectively to organizational dysfunction. The professional responsibility model guides physician leaders by proving an explicit "tool kit" to complement managerial skills.

Objective We analyzed the perinatal risks of midwife-attended planned home births in the United States from 2010 through 2012 and compared them with recommendations from the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) for planned home births. Study Design Data from the US Centers for Disease Control and Prevention's National Center for Health Statistics birth certificate data files from 2010 through 2012 were utilized to analyze the frequency of certain perinatal risk factors that were associated with planned midwife-attended home births in the United States and compare them with deliveries performed in the hospital by certified nurse midwives. Home birth deliveries attended by others were excluded; only planned home births attended by midwives were included. Hospital deliveries attended by certified nurse midwives served as the reference. Perinatal risk factors were those established by ACOG and AAP. Results Midwife-attended planned home births in the United States had the following risk factors: breech presentation, 0.74% (odds ratio [OR], 3.19; 95% confidence interval [CI], 2.87–3.56); prior cesarean delivery, 4.4% (OR, 2.08; 95% CI, 2.0–2.17); twins, 0.64% (OR, 2.06; 95% CI, 1.84–2.31); and gestational age 41 weeks or longer, 28.19% (OR, 1.71; 95% CI, 1.68–1.74). All 4 perinatal risk factors were significantly higher among midwife-attended planned home births when compared with certified nurse midwives–attended hospital births, and 3 of 4 perinatal risk factors were significantly higher in planned home births attended by non–American Midwifery Certification Board (AMCB)–certified midwives (other midwives) when compared with home births attended by certified nurse midwives. Among midwife-attended planned home births, 65.7% of midwives did not meet the ACOG and AAP recommendations for certification by the American Midwifery Certification Board. Conclusion At least 30% of midwife-attended planned home births are not low risk and not within clinical criteria set by ACOG and AAP, and 65.7% of planned home births in the United States are attended by non-AMCB certified midwives, even though both AAP and ACOG state that only AMCB-certified midwives should attend home births.

To examine the occurrence of 5-minute Apgar scores of 0 and seizures or serious neurologic dysfunction for 4 groups by birth setting and birth attendant (hospital physician, hospital midwife, free-standing birth center midwife, and home midwife) in the United States from 2007-2010.Data from the United States Centers for Disease Control's National Center for Health Statistics birth certificate data files were used to assess deliveries by physicians and midwives in and out of the hospital for the 4-year period from 2007-2010 for singleton term births (≥37 weeks' gestation) and ≥2500 g. Five-minute Apgar scores of 0 and neonatal seizures or serious neurologic dysfunction were analyzed for 4 groups by birth setting and birth attendant (hospital physician, hospital midwife, freestanding birth center midwife, and home midwife).Home births (relative risk [RR], 10.55) and births in free-standing birth centers (RR, 3.56) attended by midwives had a significantly higher risk of a 5-minute Apgar score of 0 (P.0001) than hospital births attended by physicians or midwives. Home births (RR, 3.80) and births in freestanding birth centers attended by midwives (RR, 1.88) had a significantly higher risk of neonatal seizures or serious neurologic dysfunction (P.0001) than hospital births attended by physicians or midwives.The increased risk of 5-minute Apgar score of 0 and seizures or serious neurologic dysfunction of out-of-hospital births should be disclosed by obstetric practitioners to women who express an interest in out-of-hospital birth. Physicians should address patients' motivations for out-of-hospital delivery by continuously improving safe and compassionate care of pregnant, fetal, and neonatal patients in the hospital setting.

Obstetric ethics is sometimes represented by polarized views. One extreme asserts the rights of the fetus as the overwhelming ethical consideration. Another extreme asserts the pregnant woman as the overwhelming ethical consideration. Both assertions are overly simplistic. Such oversimplification is called reductionism. This article explains the fallacy of rights-based reductionism and 2 models of obstetric ethics based on it and explains why the fetal rights reductionism model and the pregnant woman's rights reductionism model result in conceptual and clinical failure and therefore should be abandoned. The article argues for the professional responsibility model of obstetric ethics, which emphasizes the importance of medical science and compassionate clinical care of both the pregnant and fetal patient. The result is that responsible medical care overrides the extremes of clashing rights.

Objective: The current study assesses the effects of 17a-hydroxyprogesterone caproate on embryo-fetal development, with a particular focus placed on intrauterine endochondral bone development and growth. Study Design: Primigravid C57 BI/6J mice were administered 17α-hydroxyprogesterone caproate by means of subdermal pellets designed to deliver doses of 0.5, 5.0, and 50.0 mg/kg/day on gestational days 7 through 19. Assuming a dosage regimen of 250 mg per 50 kg per week in humans for the treatment of threatened spontaneous abortion, the doses used were 0.7, 7.0, and 70.0 times the human dose equivalent. The time course of exposure encompassed the period of organogenesis through the late fetal period. Results: No maternal toxicity was noted throughout the course of 17α-hydroxyprogesterone caproate administration. Fetal weight at term and the percentage of resorptions, dead fetuses, male fetuses, and malformations at term were not significantly affected at any evaluated dose when compared with control group values. The steroid did not exert a significant influence on any assessed parameter of endochondral bone development or growth, even at a dosage concentration that far exceeded the human therapeutic dose equivalent. As would be expected, fetal weight was directly correlated with diaphyseal length and also influenced the relationship of cartilage to osseous tissue in both the humeri and femora. There were no 17α-hydroxyprogesterone caproate dose and fetal sexual phenotype interactive effects noted with regard to any developmental or bone growth parameter measured, thus discounting any sexual phenotype-related toxic or teratogenic sensitivities. Conclusion: The data indicate that 17α-hydroxyprogesterone caproate administered at doses of up to 70 times the human dose equivalent did not induce increases in the frequency of genital and, importantly, nongenital teratogenesis in spite of exposure during the critical period of organogenesis. Additionally, the steroid did not affect limb morphogenesis or endochondral ossification.

Beta-adrenergic agents have been used in pregnant women forthetreatmentofprematurelaborandforthetreatment of asthma. Concerns have been expressed that exposure to terbutaline,whichisabeta-2adrenergicagonist,mayincreasethe riskofautismspectrumdisorders(ASDs)intheoffspring.This hypothesis deserves critical review, given the number of patients who have been exposed to the drug in the last 2 decades. Theresultsareimportanttoboththeobstetriciansandpatients who weigh the risks and benefits of interventions and to the pediatricians who counsel the families of affected children. We conducted an examination of the human and animal studies that have been used to support this hypothesis in a recentreview, 1 andwehavereachedadifferentconclusion.We findnosupportforthehypothesisthattheuseofterbutalineas a tocolytic agent is associated with the subsequent development of ASDs. The ASDs are common neurodevelopmental disorders that occur in approximately 1 of 150 to 1 of 100 children. 2 They are diagnosed by deficits in social interaction and communication and by restricted and repetitive behaviors and interests; the symptoms appear during the first 3 years of life. 3 Family and twin studies demonstrate that these disorders are heritable, with estimates of heritability approaching 90%. 4 However,thegeneticetiologyiscomplex,withmanylociinvolvedand nonethataccountsformorethanasmallfractionofcases. 5 Many developmental pathways seem to be involved and include those that have roles in initiating or maintaining synapses. 6,7 The penetranceofthegeneticliabilityfactorsisvariablesothatsymptoms differ, even in pairs of monozygotic twins. 8 The largest genome scan to date has added to this confusing picture the etiologic role of structural chromosomal anomalies (copy number variants), some of which arise de novo. 9 This unexpected result has been verified by other groups. 10 The known environmental risk factors for ASDs account for a small number of cases but are interesting because they share critical periods of exposure in the first trimester. 11 The identification of environmental risk factors is especially important because,unlikegeneticriskfactors,theyshouldbepreventable. Thus, it is reasonable to ask whether there is evidence that medications, such as terbutaline, to which pregnant women may be exposed increase the risk for an ASD outcome in the offspring. Our argument is not with the intent but with the quality of the evidence presented in the review by Witter et al, 1 which we now describe.

Over the past 50 years, our laboratory has provided consultations dealing with the risks of various environmental toxicant exposures during pregnancy. These contacts were primarily by telephone or written communications. Since the year 2000, the primary source of consultations has been via the internet. In 2007, the pregnancy website of the Health Physics Society received 1,299,672 visits. The contacts who downloaded information totaled 620,035. After reading the website information, 1442 individuals who were still concerned contacted me directly. Unfortunately, we have learned that many physicians and other counselors are not prepared to counsel patients concerning radiation risks. Approximately, 8% of the website contacts, who had consulted a professional, were provided inaccurate information that could have resulted in an unnecessary interruption of a wanted pregnancy. Research from our and other investigators' laboratories has provided radiation risk data that are the basis for properly counseling contacts with radiation exposures. Mammalian animal research has been an important source of information that improves the quality and accuracy of estimating the reproductive and developmental risks of ionizing radiation in humans. What are the reproductive and developmental risks of in utero ionizing radiation exposure? 1. Birth defects, mental retardation, and other neurobehavioral effects, growth retardation, and embryonic death are deterministic effects (threshold effects). This indicates that these effects have a no adverse effect level (NOAEL). Almost all diagnostic radiological procedures provide exposures that are below the NOAEL for these developmental effects. 2. For the embryo to be deleteriously affected by ionizing radiation when the mother is exposed to a diagnostic study, the embryo has to be exposed above the NOAEL to increase the risk of deterministic effects. This rarely happens when the pregnant women have x-ray studies of the head, neck, chest or extremities. 3. During the preimplantation and preorganogenesis stages of embryonic development, the embryo is least likely to be malformed by the effects of ionizing radiation because the cells of the very young embryo are omnipotential and can replace adjacent cells that have been deleteriously affected. This early period of development has been designated as "the all-or-none period." 4. Protraction and fractionation of exposures of ionizing radiation to the embryo decrease the magnitude of the deleterious effects of deterministic effects. 5. The increased risk of cancer following high exposures to ionizing radiation exposure to adult populations has been demonstrated in the atomic bomb survivor population. Radiation-induced carcinogenesis is assumed to be a stochastic effect (nonthreshold effect) so that there is theoretically a risk at low exposures. Whereas there is no question that high exposures of ionizing radiation can increase the risk of cancer, the magnitude of the risk of cancer from embryonic exposures following diagnostic radiological procedures is very controversial. Recent publications and analyses indicate that the risk is lower for the irradiated embryo than the irradiated child, which surprised many scientists interested in this subject, and that there may be no increased carcinogenic risk from diagnostic radiological studies. Examples of appropriate and inappropriate counseling will be presented to demonstrate how counseling can save lives and change family histories. The reader is referred to the Health Physics Society website to obtain many examples of the answers to questions posed by women and men who have been exposed to radiation (www.hps.org). Then click on ATE (ask the expert).

This article will deal with medical, social, and legal implications of treating nausea and vomiting of pregnancy (NVP). Clinical problems occur when the symptoms become exaggerated and result in debilitation, dehydration, and hospitalization. The treatment of NVP in its early stages has the implication that it will prevent the more serious complications, including hospitalization. Therapeutic modalities discussed in this conference that have been used or are being tested are primarily symptomatic treatments (antihistamines, Bendectin (Merrell Dow; Cincinatti, Ohio), phenothiazines, hypnosis, accupressure, relaxation behavioral modification, audiogenic feedback training, newer medications, diet, and nutritional support). Bendectin is probably the most studied medication with regard to its reproductive effects, and the studies clearly demonstrate that therapeutic doses of Bendectin have no measurable reproductive risks to the mother or the fetus. In spite of Bendectin's record of safety, numerous nonmeritorious congenital malformation lawsuits were filed and went to trial, and that junk science was presented at these trials. The Bendectin era focused our attention on the area of nonmeritorious litigation and junk science, which could have an effect on any new or less well-studied therapies, because such a high percentage of women are treated for NVP. Because 3% of the offspring will be affected with birth defects, the potential for litigation is immense. The solutions are (1) for legal problems, the medical community should focus their attention on junk scientists and their junk science, over which physicians should have some authority, and (2) for the treatment problem, it would seem most logical that a major research effort should be directed toward brain receptors that are involved in these physiologic effects. Furthermore, it would be imperative to study the array of molecules, both natural and manufactured, that can interact with these receptors for the amelioration of nausea. Until we understand the mechanism and specific therapy for NVP, it would appear that the reintroduction of Bendectin is the logical intermediate course to follow. We should also accompany the introduction of Bendectin with an educational campaign with regard to the lack of reproductive risks for this medication. The Food and Drug Administration has set the stage for the reintroduction of Bendectin by republishing their conclusion that Bendectin does not represent an increase in reproductive risks to the fetuses of pregnant women.

Objective We examined neonatal mortality in relation to birth settings and birth attendants in the United States from 2006 through 2009. Study Design Data from the Centers for Disease Control and Prevention–linked birth and infant death dataset in the United States from 2006 through 2009 were used to assess early and total neonatal mortality for singleton, vertex, and term births without congenital malformations delivered by midwives and physicians in the hospital and midwives and others out of the hospital. Deliveries by hospital midwives served as the reference. Results Midwife home births had a significantly higher total neonatal mortality risk than deliveries by hospital midwives (1.26 per 1000 births; relative risk [RR], 3.87 vs 0.32 per 1000; P P P P Conclusion Our study shows a significantly increased total and early neonatal mortality for home births and even higher risks for women of 41 weeks or longer and women having a first birth. These significantly increased risks of neonatal mortality in home births must be disclosed by all obstetric practitioners to all pregnant women who express an interest in such births.

Advances in modern medicine invite the assumption that medicine can control human biology. There is a perilous logic that leads from expectations of medicine's control over reproductive biology to the expectation of having a perfect baby. This article proposes that obstetricians should take a preventive ethics approach to the care of pregnant women with expectations for a perfect baby. We use Nathaniel Hawthorne's classic short story, "The Birthmark," to illustrate the perils of the logic of control and perfection through science and then identify possible contemporary sources of the expectation of the perfect baby. We propose that the informed consent process should be used as a preventive ethics tool throughout the course of pregnancy to educate pregnant women about the inherent errors of human reproduction, the highly variable clinical outcomes of these errors, the limited capacity of medicine to detect these errors, and the even more limited capacity to correct them.