Ah, the doctor’s letter. This would be the version of Mrs. Palin’s “medical records” that she promised during the campaign.
The letter is short, as was President Obama’s, but it was only released by the McCain campaign an hour or so before midnight on election eve, 2008. It also differed from Mr. Obama’s in that the bulk of it concentrated on the birth of Trig Palin. The Obama children, their births and health, were not mentioned in his letter.
Much has been written on several excellent blogs about Mrs. Palin’s letter. Cathy Baldwin-Johnson, who calls herself the Palin family physician, signed the letter. A PDF of the document archived with the Los Angeles Times can be found HERE.
And Regina at Palingates recent post on the matter can be found HERE.
Others have questioned everything about the letter, from the doctor’s signature, to the formatting, to the passive voice. I found the letter odd in several ways, not the least being the fact that the McCain campaign released it, purposefully of course, at a time when no reporter could scrutinize it or press for answers.
Why was that, Steve Schmidt?
To sort out what others see as discrepancies, I asked the neonatologist, with whom I have been speaking on this blog, to offer his expert opinion.
LN: So, does this letter state that Sarah Palin was pregnant and gave birth to Trig Palin in 2008?
DOC: It does say that she was pregnant and delivered a baby with Down’s syndrome in 2008 at 35 weeks gestation. It’s very vague and doesn’t mention a birth date, but it does spend more time on this pregnancy than any of the others. Others have noticed that it leaves out her two miscarriages and gets the year of Piper’s birth wrong.
I’m most interested in the part that says that the diagnosis of Down’s syndrome was made early in the 2nd trimester and confirmed by amniocentesis. I find this point interesting, because most pro-life or highly religious parents who I work with decline amniocentesis. In fact, they often get offended when I ask them about the pre-natal genetic testing. I often hear “It’s god’s will and we’ll accept the baby that god gives us”. Amniocentesis carries a 1-2% miscarriage risk, and even if positive for something serious, the parents aren’t going to terminate the pregnancy based on the information they receive. There’s a rule in medicine: “Don’t do a test if you aren’t going to do anything with the results” and it certainly applies here.
The generic nature of the narrative suggests to me that she could have easily been describing Bristol Palin’s pregnancy. Perhaps Bristol, without strongly held beliefs about abortion like her mother, wouldn’t have objected to an amniocentesis in the face of suspicion of Down’s syndrome.
LN:L What do you make of the fact that the baby’s specific birth DATE is missing? Would you put a date in a letter if you were writing it? Is that important?
DOC: Dates are critical in neonatology as we deal in premature babies and want to know exactly how premature a baby is. The exact date of Trig’s birth is very important. If Trig was born 3 or 4 weeks earlier than otherwise claimed, Bristol could have been the mother of both babies. The letter does not give a specific date for Trig’s birthday and if the letter were written for the implicit purpose of confirming Trig’s parentage, a specific date would have been expected. On the other hand, in most medical records that I read, only the year is given, so I don’t want to read too much into this.
LN: Is there anything out of the ordinary in the letter?
DOC: It says nothing out of the ordinary except that the doctor changed her status at the hospital on June 1, 2008 to "devote more time to my work in the area of child abuse evaluation and prevention". The timing is interesting. If CBJ was board certified in 1983 then that puts her age somewhere in the 50s assuming a normal career path. Most doctors don’t start cutting back their time until they reach their 60s. Also, how is this relevant to Sarah Palin’s health? Why include this in a letter about her?
LN: Do you surmise from it that the doctor is telling the truth (passive voice and odd narrative not withstanding.)
DOC: I'm actually not all that bothered by the use of passive voice in the letter. It's pretty typical of medical written communication. That's what they tell us to do in medical school. I think she's telling as much of the truth that she can except for Trig's pregnancy. I'd still like to know if she was Bristol's doctor too, but there’s no reason to put that in the letter.
LN: So what do you mean except for Trig's pregnancy? Doesn't she say that she was Mrs. Palin’s doctor during this pregnancy and that she followed routine prenatal care? Tell me if there is a clue as to what's missing.
DOC: I mean that she tried to include as much factual information in the letter as possible to give it credibility. From the letter, we are supposed to assume that she was Sarah Palin's doctor during Trig's "pregnancy". I don't see any clues to anything amiss in the letter. However, it would be simple for her to attribute the care of Bristol Palin's pregnancy with Trig to that of Sarah.
LN: In other words, mix two cases or names: Blend the daughter’s possible pregnancy chart and attribute it to the mother?
DOC: Yes, that’s exactly what I’m saying.
LN: But isn’t that precisely what would be unethical, if not illegal? Isn’t the entire point of a medical record to go on the record about that one patient?
DOC: Yes, and that’s why I find the fact that she went off active status in June 2008 to be interesting. If she had continued on after that point, her medical records might have received extra scrutiny by the credentialing committee at the hospital that she didn’t want to deal with.
LN: So herein lies the rub: If a doctor fibs about a patient to the public, that’s one thing. But any record of that can be discovered by the State during an audit for credentialing. And that could jeopardize an entire facility. So, is it possible she bowed out of her role there in order to staunch any bleeding that could occur down the road for the hospital itself? No matter how entwined she was with them?
DOC: The state handles licensing and each hospital handles credentialing. The state usually doesn’t act against a practitioner unless there is a specific complaint or if standard requirements aren’t met. Hospital rules for credentialing vary, but most require renewal every 2-4 years and any concerns or complaints are evaluated by the credentialing committee. Obviously, the process for “active” staff is more robust than for “courtesy” staff. In this particular case, it wouldn’t surprise me if CBJ struck some kind of deal with the hospital that she would downgrade to courtesy staff and they wouldn’t push back with any kind of investigation. Hospital administrators hate controversy.
LN: Would you write that letter if you were NOT that woman's doctor? (May not be illegal, but it's sure a lie or unethical.)
DOC: No way! If I was given access to her medical record and wasn't her doctor, I would make it clear that I wasn’t her personal physician.
LN: So either this truly is Mrs. Palin’s doctor writing the truth, or…tell us under what circumstances a doctor might do this? Have you ever known one to not tell the whole truth in a letter like this?
DOC: I think CBJ may have already been too deep in this mess to bail out. If she had lied about Trig’s mother, she would have to continue to support that lie to keep her professional status intact. I don’t know of any cases in my experience like this, but as I have mentioned before, it is very easy for a doctor to get caught between doing the right thing and doing what their patients ask them to do.
LN: One of the things people have criticized is that the letter does not state that Dr. Baldwin-Johnson delivered the baby Trig. I don't see any issue about naming who actually delivered the child. It could well have been the OB on call at that hour, especially if Dr. CBJ induced labor at 11:30pm. She might simply have gone home.
DOC: Absolutely, the on-call doc for the practice handles the delivery. No one but the most important VIP gets a guarantee to have their doctor at their delivery. The only exception would be the rare case of a true solo-practitioner. I will say, however, that OBs (and Neonatologists) often do 24-hour shifts for continuity of care.
LN: Well, for a little levity, allow me to say I am flattered. My OB put in a 12-hour day and stayed to deliver my son and I was little more than a TV reporter (34-years-old, prima gravida. Etc., etc, and yes, she and I could both say exactly where and when he was born without mixing up our stories!)
DOC: Well speaking of that kind of wording (prima gravida et al.), I wonder if the records from Bristol’s "2nd" pregnancy indicate anything about her past OB history. Did someone write anything in her chart like her being a G2 P0101, which is OB for "2 pregnancies, one living preterm birth"? HIPPA protected, for sure, but interesting. Maybe Bristol will some day run for political office and have her medical records disclosed.
We often have moms who come in and say its their first pregnancy, but when the OB examines them, it's clear that they have episotomy or perineal laceration scars. That could also be in the chart.
LN: So you think this letter could have been referring to Bristol giving birth to Trig?
DOC: The letter doesn’t answer that question directly, but it certainly doesn’t settle the issue either.
LN: And that’s the key here, in my opinion. They release a letter at, literally, the eleventh hour, with all this wording in order to settle a controversy, and yet it does precisely the opposite: It remains vague and scattered enough to ensure that the controversy continues. Why is that?
DOC: I’m not sure what the law says about this, but the purpose of a doctor’s letter is to attest that a candidate has no significant health problems that would prevent them from fulfilling the office that they aspire to. In this case, they had a dual purpose. One was the standard statement of good health. The second was to use this as an opportunity to support the vice presidential candidate’s claim that she was Trig’s mother. The fewer details that CBJ put in the letter, the fewer details she could potentially have to defend later if/when the medical records are examined. However, it’s more of a political question than a medical question. I’m sure the McCain/Palin people went over that letter with a fine-toothed comb before releasing it.
LN: But this is all just speculation, because the truth is, we’ll never know, am I right? Especially with a famous patient.
DOC: There is no obligation to release medical records for public examination. Eventually, they may leak out to the public, but I wouldn’t hold my breath. It’s no different for a famous patient. When doctors have a famous patient, the rules are very simple. If you say anything to anybody about their health information, even to your own friends and family, you can look for a new job. We once had a prominent football player's baby in our nursery. Some staff that weren't caring for the baby or mother opened up the mother’s electronic medical record out of curiosity and were promptly fired.
LN: So, bottom line, if you were NOT Mrs. Palin’s doctor, you would not have written this letter? So, we have to assume that Cathy Baldwin-Johnson was on the up-and-up here.
DOC: She says that SP was seen "as a patient in our clinic since 1991". I see no reason to doubt that.
LN: Except that they shared a religious affiliation that oversaw the Board of the hospital. Long time followers of the story can add more detail to this, I am sure.
DOC: Now that's scary. Especially since Sarah flew quite a long way to deliver at this specific little hospital. That's the part that makes the least sense in the whole story.
LN: So, what, if anything, leaves any doubt or questions in your mind about this letter?
DOC: It’s a rather bland, routine medical letter as it should be. I have no idea why the “FP” at the end of FAAFP is in different color. Not sure it means anything. The three things that strike me as unusual or suspicious are Dr. CBJ resigning from active status at the hospital shortly after Trig’s birth, the amniocentesis, and the fact that Trig’s birth date is not given.
LN: Let’s talk soon about the photos of the alleged newborn Trig. I have some thoughts about them but more importantly I’d love it if you could offer your own perspective as someone who has specialized in the care of high-risk and medically fragile newborns and children.
DOC: I assume you’re talking about the photos of him being held by friends and family, looking chubby and pink? I don’t see any jaundice in those pictures, nor do I see the normal “plethora” (or ruddiness) that most babies have in the first day or two of life. He also looks too chubby for a newly born baby; at least a few weeks old, but definitely not a new 6lb, 35 weeker. That looks more like one of those babies they use on soap operas who is 1-2 months old playing a newborn.
LN: Thank you, Doc! That comment alone should get everyone’s juices flowing. I’ll try to pull together the photos and we’ll dissect them.
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