Clinician, Activist, and Thought Leader who Challenged Accepted Obstetric Care
Family Physician, Pediatrician, Neonatologist, Maternity Care Researcher, Maternity, Primary Care and Organizational Consultant
“Refusing to serve as an officer in the US Army Medical Corps during the Viet Nam War, he fled to Canada in 1967 with his wife Bonnie. He became a family practitioner, pediatrician, advocate, professor, and researcher at McGill and the University of British Columbia. Michael Klein has played a vital role in placing maternity care at the heart of family medicine. Motivated by concerns over the harmful effects of certain then widespread medical interventions, he pushed for the adoption of family-friendly birth practices, the re-introduction of midwifery, the promotion of doulas in birth and the elimination of routine intrusive interventions such as episiotomy. An influential mentor to many, his approaches are now widely adopted in maternity care.” Citation for the Order of Canada 2016.
For the full story of his lifetime of activism, research, and pioneering work in family medicine, see his personal website
Watch the video of the interview below or on Youtube or listen to the podcast on Spotify and all the major platforms
“The term ‘red diaper baby’ refers to the children of the left wingers, which goes back to the McCarthy period (in the USA). So, I was one of those. My parents were very radical for the time and we were a generation of babies who lived and grew up in the shadow of McCarthyism.”
Today we’re in Vancouver and I’m talking to Professor Michael Klein.
Michael, you’ve influenced generations of primary care researchers, but more importantly, you have never been afraid to challenge the status quo. You described yourself once as a ‘red diaper baby’. Tell us what that means…
Michael Klein: The term ‘red diaper baby’ refers to the children of the left wingers, which goes back to the McCarthy period (in the USA). So, I was one of those. My parents were very radical for the time and we were a generation of babies who lived and grew up in the shadow of McCarthyism.
DMacA: Your first degree was in political science, which must have fed that enthusiasm for challenging politics?
MK: Well, it was partially that, but it was also that I really didn’t want to be hanging around with pre-med students. So, I took the bare minimum to get into medical school but I was majoring in political science at Oberlin College.
DMacA: Tell us about that experience.
MK: Oberlin College is a small Midwestern college with a unique history. It was the first college to admit women in the United States, it was a stop on the underground railroad, and it was the first college to admit Blacks. It was and remains very liberal but much more than liberal in its foundation.
DMacA: When did you decide to do medicine and how did that undergraduate medical training go?
MK: It was hard for me because I wasn’t particularly good at maths and, political science does not prepare you for medical school. I actually prepared for both medicine and law. I took the medical boards and the law boards and I scored marginally better in medicine so I went for medicine. But getting into medical school was not easy either, and that’s a whole story in itself, but I did get into Stanford Medical School, which was clearly the right choice for me.
DMacA: Stanford was a pretty high bar!
MK: It was huge. I mean, they were about producing the physician scientists. At the time it was a five year medical school and I had among my classmates a number of people who already had their PhDs. Meanwhile, I was struggling to just survive the basic medical sciences. So, once again, generous classmates, who found the basic sciences to be no problem at all, helped me through,
DMacA: Were you an activist when you were at medical school?
MK: Well, I was active a couple of levels. I joined the student American Medical Association and was working for single payer health, something which we have in Canada and we still don’t have in the United States. So, I was active there right from the beginning in the 1960s, I was also very much involved with the anti-Vietnam War movement at the time.
” When I was in medical school at Stanford, I never saw a family doctor. And if you never see one, you can’t be one. And, so my connection was with paediatricians who shared my politics and view of life. And so I became one of those.”
“Earthenware Containers as a Source of Fatal Lead Poisoning — Case Study and Public-Health Considerations”. September 1970 N Engl J Med
“Low birth weight and the battered child syndrome” July 1971 Am J Dis Child
DMacA: So then you trained in paediatrics…
MK: Well, when I was in medical school at Stanford, I never saw a family doctor. And if you never see one, you can’t be one. And, so my connection was with paediatricians who shared my politics and view of life. And so I became one of those. I trained originally in New York, at the Albert Einstein College of Medicine. I never heard of general practice, Stanford was certainly not the place for that, and so I became a trainee in paediatrics and eventually was a certified paediatrician and later became a certified in neonatal perinatal medicine and ran newborn intensive care units
DMacA: Along the way you’ve had this golden career: Stanford, Albert Einstein, you’re a neonatologist, but your life took a major turn in 1967. Tell us about that…
MK: Well, that story is rather fraught. It was very clear to me early on that I was not going to have anything to do with the Vietnam War, which was illegal, and immoral, and frankly, stupid. I intended to stay out of the military. Unfortunately, every physician in those years was drafted unless you had an alternative with the Public Health Service or something similar. So, I approached it from that point of view and I actually had an appointment given to me in the US Public Health Service, at the CDC, the Epidemic Intelligence Service, and that would have got me out of the military. Unfortunately, when they sent a routine inquiry to my draft board about my status, they said that I was a conscientious objector, when I was only an applicant. When the US Public Health Service got that response they removed me from the Public Health Service because, in times of national emergency, the Public Health Service could become an arm of the military. I was then drafted and I was actually inducted as an officer in the U.S. Military Medical Corps.
That was a moment of truth for us, because there was no way I was going to do that and I was headed for jail. I was going to go to jail rather than be part of the military. My wife Bonnie and I had some deep conversations about that and we decided that going to Canada was much preferable to jail. So, we set out secretly to go to Canada and in the interval between being inducted as an officer in the Medical Corps and getting my actual military assignment, we escaped to Canada in the middle of the night and I got ‘landed immigrant status’ in Canada in 20 minutes.
DMacA: In Canada, you straddled the three disciplines of paediatrics, family medicine and, of course, your research in obstetrics. Tell us about your career as you went through McGill and into UBC.
MK: As I said, I knew nothing about family practice so I became a paediatric resident at the Montreal Children’s Hospital, completed that training and became chief resident in paediatrics at McGill. Remember I still have not discovered family practice. When I finally finished my training at McGill, and was a certified paediatrician, I wanted to study community paediatrics which, at the time, was not available in Canada. So, I returned to the United States to do that at the University of Rochester. I managed to get back to the United States through a very complicated process. It wasn’t amnesty, like Jimmy Carter’s amnesty but, to make a long story short, I had convinced the military that I was more trouble than I was worth. So that’s when I went to Rochester, New York. What happened there was that, while doing my fellowship in community paediatrics, I developed a series of three neighbouring health centres. I was practicing as a paediatrician in one of the centres but I found that for inner city people, the complexity of having a paediatrician, an internist, a psychiatrist, an obstetrician, was just too much for these complex very needy families. And, I discovered the model, which was the one that was needed, in the family practice model. I never considered that I would become one but after five years, I took the family practice boards and became an official family doc.
On the first day of my rotation in obstetrics, I had just completed a birth when I felt a heavy hand on my shoulder. It was the Professor and Chair of Obstetrics at Stanford, and he said to me, and these are his exact words, “Mr. Klein, if you want to practice primitive obstetrics, you’ll have to go to the county hospital.”
Michael and Bonnie meet the Queen Mother
DMacA: As an academic family doc in Vancouver you did some remarkable research and, indeed, you did a piece of research that actually changed the world, which was your trial on episiotomy. Tell us about that work…
MK: Well, we have to go way back because, while I was a medical student at Stanford, I got an international child health fellowship and I went to Ethiopia. It was supposed to be for six months but it was an extraordinary experience because I was the only medical student in the children’s hospital in Addis Ababa, and I didn’t want to leave.
What used to happen back in Ethiopia was that when I had ‘put the babies to bed at night’, figuratively, and being a keen medical student, I would sometimes wander over to the adjacent hospital, The Princess Tsehai Memorial Hospital, named after one of the daughters of the Emperor Haile Selassie, and I would attend births with the support of midwives who did all the births there. Paradoxically, I had not completed obstetrics yet at Stanford and I was getting experience under the support of the midwives in Ethiopia, and I learned to do births the way they did births. Those births were much less interventionist than the typical births that took place in normal obstetrics. I not yet trained in obstetrics so I considered that what I learned from the midwives in Ethiopia to be normal practice.
When I got back to Stanford to finish my training, one rotation of which was in obstetrics, I confronted something that I did not expect. On the first day of my rotation in obstetrics, I had just completed a birth when I felt a heavy hand on my shoulder. It was the Professor and Chair of Obstetrics at Stanford, and he said to me, and these are his exact words, “Mr. Klein, if you want to practice primitive obstetrics, you’ll have to go to the county hospital. So, he exiled me from the Stanford University Hospital to the county hospital and, in US medicine, the county hospital is where poor people go who do not have insurance coverage. The same is true today.
Let’s return to the trial. The trial that I did was, and still is, the only randomized controlled trial of episiotomy in North America. The trial took place in three Montreal hospitals, and to oversimplify, the trial showed that routine episiotomy caused the very trauma that it was supposed to prevent. It was a struggle to get funding for it, and a bigger struggle to get published in conventional journals. I was turned down by the New England Journal of Medicine and JAMA and other places. The comments of the reviewers were over the top. They were misogynistic and crazy, frankly. I then submitted to the American Journal of Obstetrics and Gynaecology and received the usual crazy reviews. At that point, I couldn’t take it anymore so I called the editor of the journal read him the actual reviews and he was frankly embarrassed. He sent the study out again to his hand-picked reviewers and, not only was it published, but it was published in a series of three articles. That basically changed the view of conventional obstetrics about episiotomy and the episiotomy rates in the United States and Canada dropped from 60-80% to about 20% in a few years, and it led to a reduction in severe trauma to the mother from 4.5% to less than 1%. It was clearly the most important thing that I’ve ever done and it was accepted widely, and the section of the conventional obstetrical textbooks had to be rewritten, and they were. And today’s obstetricians are practicing normal births with episiotomy done only selectively and not routinely. That was a huge change.
At my own hospital in Montreal, which was the Jewish General Hospital, there hadn’t been a family doctor who had attended a birth in 15 years. I started attending births with the support of a lovely obstetrician who attended my births for about six months, at which point she said – this is a waste of her time. And she said, just do it. And so I did. And then I hired family doctors who would do obstetrics as well so, by the time I left for Vancouver in 1993, we had gone to about a thousand births a year, which was a huge thing in Montreal, where family doctors didn’t attend births. And, so we transformed that whole ethos in Montreal. And, that’s the way it was when I was finally recruited to be head of family practice at the Women’s and Children’s Hospitals in Vancouver in 1993.
The other thing that was happening, which was very controversial, was that I was embracing the new “discipline of midwifery” and many family doctors in my own department were very uneasy with that…Some were really furious about it and a small coterie of them actually tried to have me impeached because of my support for midwifery.”
DMacA: You’ve now moved back to Vancouver and you have all these ideas for research, particularly in obstetrics so tell us a little bit about your work in obstetrics through the lens of family medicine.
MK: As head of family practice at Women’s and Children’s hospitals, I was head of a department that had never done any research at all. And, around the same time, midwifery was coming back in Canada from a long dormant period. So, I was doing two things, apart from running, which was then and still remains the largest group of family doctors attending births in Canada, which was one of the attractions of the job for me in the first place.
By the way, the real reason for moving to Vancouver was because of my wife’s illness. She had a brain stem stroke 36 years ago and was unable to deal with Montreal winters. She drove a scooter, which doesn’t work on snow. So, I knew I had to leave Montreal even though I didn’t want to. And, I was recruited by UBC and then chair Carol Herbert, (https://medicsvoices.com/carol-herbert-primary-care-and-participatory-research/ ) who kind of created this position for me, hoping that this department would do research as well, because it certainly had the capacity to do it.
I began looking at family practice as an opportunity to do research and also to improve and strengthen the discipline at the same time. I did a number of studies, one of which had to do with volume of obstetric patients. At that time there was great suspicion, particularly at the Society of Obstetricians and Gynaecologists of Canada, that family doctors with low volume could be putting their patients at risk. I saw no evidence for that, but I felt that we needed to study it in a careful way. That was one example. The other thing I did, which was resisted to a certain extent by my own department, was to provide the actual data, confidentially, to every member of the department for all the various component parts of maternity care. Every year they got their episiotomy rate, their forceps rate, their caesarean section rate, their resuscitation rate etc. and they got it confidentially, meaning that I prohibited myself as chair from knowing the results. They could see themselves compared to the other members of the department and could see themselves against their colleagues and, without any other intervention than that, people started changing and the department rate of episiotomy went from 60% to 12%. And the severe trauma rate went to less than 1% from about 5%. And that was an intervention all by itself. So I did that type of study where we were looking at ourselves.
The other thing that was happening, which was very controversial, was that I was embracing the new “discipline of midwifery” and many family doctors in my own department were very uneasy with that. They felt that somehow, for the head of family practice to support midwifery, was a betrayal of the discipline of family practice. Some were really furious about it and a small coterie of them actually tried to have me impeached because of my support for midwifery. The hospital, would have none of it. And, in fact, what I did is that I established, in the pre-legalisation phase, a group of family doctors who would support midwives before legalization so that the midwives could prepare for legalization. And, because we had been so supportive of midwives over this period, when midwifery became legal, they had to decide where they would locate themselves academically, and they decided to become a division of family practice, which is where they are now. And I feel really satisfied and fulfilled in terms of the role that I played in making that more likely to happen.
Watch Michael tell the story of his self diagnosis and subsequent treatment of an aortic dissection. It is published as a full case report in Canadian Family Physician and on the McGill website.
Governor General David Johnston, right, presented the insignia of the Order of Canada to Michael Charles Klein on May 12, 2017.
Photo credit:Sgt Johanie Maheu/Rideau Hall/Office of the Secretary to the Governor General
DMacA: And it’s a tremendous accolade to you. Looking at you as someone who was nearly arrested by the US, and impeached by you colleagues in UBC, and who really challenged authority along the way, it must have been a wonderful feeling to be awarded the Order of Canada.
MK: I’ve had lots of awards over the years, but that’s the most important because its the highest civilian award that is given by Canada. And that ceremony was very powerful for me and validating and, I’m obviously very proud of it.
DMacA: Michael, it’s been just a pleasure to chat to you. Thank you so much for sharing so much of your life and your career and we should all be very grateful for your leadership and for your inspiration. Thank you very much indeed.
