Introduction
Obstetricians are struggling in the current
economic environment. There are soaring malpractice expenses. Reimbursement is
at 1980 levels (1). Students
are not attracted to the field and residency positions go unfilled. The life
style associated with obstetrics is unattractive to women physicians trying to
balance career and family. The purpose of this paper is to examine the application
of the hospitalist model to obstetrics as a means of addressing the problems
plaguing the field.
Hospitalists are
doctors whose primary professional focus is on the care of hospitalized
patients. Hospitalists' activities include patient care, teaching, research,
and leadership related to in patient hospital care. Hospitalists are not a new
concept. The word "Hospitalist" was first used in 1996 in a New England
Journal of Medicine article (2). Since then hospitalists have become the “dominant
model of inpatient care” (3). Hospitalists are currently employed in 40% of the nation’s
hospitals. The specialty has gained acceptance. It is estimated that there will
be 25,000 hospitals in the
There is an extensive literature on
Hospitalists. A Medline search performed on
Drs. Wachter and Goldman (5) published a meta-analysis which reviewed 19 published studies regarding the impact of hospitalist programs on all aspects of health care delivery. They concluded that Hospitalists decrease hospital costs and patient length of stays. They found that patient had high levels of satisfaction with care by the Hospitalists. They also found high levels of job satisfaction among the doctors who chose to be Hospitalists. They could not determine from the studies if Hospitalists improve the quality of care. The doctors they studied came from a wide variety of training backgrounds. They were trained in internal medicine, pulmonary, critical care, family medicine or pediatrics. None of them were trained in obstetrics and gynecology.
To date, there are no scholarly articles describing the role of the hospitalist and obstetrical care. Although there may not be any medical or business literature about obstetrical hospitalists, there are 10 hospitals using a Hospitalist model to provide inpatient obstetrical care (6). Even though there are no published research articles, there are opinions from several experts in obstetrics.
Elizabeth
Puscheck, MD, an officer of the Association of Professors of Gynecology and
Obstetrics, wrote about the hospitalist movement saying “In Europe, they employ
a different model. The patients see their doctor of choice in the office, but
see a “hospitalist” when they are admitted to the hospital. Some may argue that
this approach is not acceptable to our patients that the doctor-patient
relationship is important and we need to follow our own patients. However, it
is rare these days that physician deliver all of their own patients. Group
practices, which are much more common than solo practices in ob-gyn, have
enabled us to improve our lifestyle at the expense of some personal contact
with patients. Some internal medicine practices in the
Another notable
leader who is supporting the application of the hospitalist model to obstetrics
is the chairman of the Department of Obstetrics and Gynecology at Thomas
Jefferson University Jefferson, Louis Weinstein, MD. He has coined the phrase
“laborist” to describe a “physician whose sole focus of practice is managing
the patient in labor” (8). I had the good fortune to meet with Dr. Weinstein on
Description of the
Role of Laborist in Patient Care
Obstetrics is the only specialty in medicine where all of the patients will require hospitalization. The chief role of the laborist is to manage the inpatient care of pregnant women. Their other responsibilities include education of the residents and medical students, participating in the multidisciplinary team for patient care, participating in clinical research, and working within the hospital infrastructure so that optimal patient care can be provided for the least cost and maximal patient satisfaction.
Obstetrical patients would be cared for prior to delivery as outpatients by community obstetricians. When it is time to be delivered, the patients will be admitted to the hospital and cared for by a team of expert obstetricians whose sole responsibility is the patient in the hospital. They will be cared for by laborists during their in-patient stay and then returned to the care of the community physician after discharge.
These physicians
would work in a team that allows for coverage 24/7. The laborists will admit
and coordinate the care of selected pregnant patients admitted to the hospital
for labor and delivery. Before the delivery, the community obstetrician will
share the information on prenatal care, obstetrical complications, family and
social concerns with the laborist who will be assuming the patient's care. During
the period of hospitalization, decisions regarding care, consultation,
admission, transfer and discharge should be the sole responsibility of the laborist
in consultation with the patient and family members. Information about the
delivery will be communicated to the community obstetrician. The doctors
serving as the laborists will be board certified OB-GYN physicians whose
education, training, and current competence qualify them to serve effectively
in this role.
Advantages
for the Patient
The first advantage for the
patient is availability of physicians. The laborist is immediately available
throughout the day and night to examine patients, evaluate the progress of
labor, react to laboratory abnormalities, and provide a safe delivery. There is
no delay as a doctor travels from his office to the hospital. There is no delay
to the doctor’s arrival so he can “finish up office hours”. As all
obstetricians know, there can be lightning fast changes in the care of the
obstetrical patient. Things can go from fine to disaster in just a few minutes.
If an emergency occurs, the laborist is already on the scene, ready to respond
with lifesaving intervention. The presence of a doctor full time in Labor and
Delivery could improve patient outcomes and decrease liability due to delays in
care.
The laborist is available at the hospital
whenever the patient or family member has questions regarding care. They can
respond immediately to patient needs for anesthesia. They can comfort and
reassure an anxious family. They can evaluate worrisome fetal heart rate
tracings and use monitoring judiciously.
Another advantage of a
laborist is to
allow for more patient options. Many doctors do not offer their patients a
trial of
Another advantage for
patients of a laborist is expertise and optimal patient care. The doctor who
will be doing the delivery is an expert in all the different delivery
techniques. A doctor must be skilled in the specialized delivery skills in
order to avoid complications. As the patient care obligations shift more to the
out patient areas, it is difficult for doctors to acquire and maintain the
obstetrical skills needed for optimal inpatient outcomes.
An example of specialized
delivery technique is the use of obstetrical forceps. The rate of forceps use
has declined 43% from 1980-1987 (10). During the same interval the cesarean
section rate increased 49% (10). Many young doctors lack experience in using
forceps. Dr. Chez (11) described the clinical experience reported by candidates
for the American Board of Obstetrics and Gynecology 1995 and 1997 examination.
The data collected on the doctors taking their oral examinations showed that
the mean forceps use in 1995 was 6 with a standard deviation of 7.7. It was 5
in 1997 with a standard deviation of 6.1. The mean total deliveries reported
were 132 +/- 70 and 127 +/-65.8. It is
challenging for a doctor to keep up his skills because of the infrequency of
difficult deliveries. Forceps may not being used when they could spare a
patient an unnecessary c-section because doctors are afraid to trust their
unpracticed skills.
The laborists would be expert at difficulty
delivery because they would have more experience than the community
obstetrician. In addition to forceps deliveries, they will be more skilled at
other obstetrical techniques including external cephalic version, twin
deliveries, vacuum extractions, pre-term deliveries, face presentations, breech
deliveries, and dealing with other malpresentations. This added expertise is
not only valuable to patients but it is valuable to the hospital and the health
system by decreasing costs. Adams et al (12) reported in 2000 that the 15% of
all abdominal deliveries in the
Another advantage for
patients is communication with other professionals within the hospital. The laborist
will be familiar with
all of the key players in the hospital including medical and surgery
consultants, discharge planners, social workers, clergy, and others. They can
expedite care for patients. The amount of phone tag between consultants
and community obstetricians would be reduced. The laborist can easily facilitate
connections with providers of home health care, skilled nursing, specialized
rehabilitation, and others. The biggest advantage is that because they are in
the hospital, they can recognize outliers, anticipate problems and rapidly
respond to crises or changes in a patient's condition.
Advantages
to the community obstetrician
The first advantage the laborist
would provide for community physicians is increased revenue. The laborist
can free the community
OB-GYN from hospital distractions and provide the community physician the time
to focus their attention on their office practice. Wachter and Goldman (5) reported
than “the average primary care physician would realize a yearly net gain of
about $40,000 by forgoing hospital care, simply by replacing wasted commute
time with increased ambulatory productivity”.
According to the ACOG News
Release of October 31, 2000 (34), Ob-Gyns averaged 95 patient visits per week.
The average annual number of births was 141: 115 vaginal and 26 cesarean. This
averages out to 2.7 deliveries per week.
Similar information was noted
by Merritt, Hawkins & Hawkins in their 2003 OB/GYN Malpractice survey of
ob-gyns (13). The average doctor has 3,616 patient visits in the office
annually. This averages out to ~70 patient visits per week. He performs 115 deliveries annually. This
averages out to 2.2 deliveries per week. Either his sleep is going to get
ruined twice each week or his office hours are going to get wrecked twice a
week. If office hours are delayed, then patients face long waits. It costs
doctors thousands of dollars in lost revenue to miss office hours (14). The
lost income cannot be fully recovered from the rescheduled patients (14).
Another advantage for the
community physicians the laborist can have is a major impact on life style. A 2003 ACOG News
release (15) reported that “nearly one-fourth of ob-gyns were somewhat or very
dissatisfied with their careers, placing them 30th among 31
specialties in career satisfaction. Among the contributing factors was “quality
of life issues raised by the long hours in ob-gyn.”
Many medical students are
attracted to obstetrics but do not pursue it because of the difficult
lifestyle. Many excellent students look to other medical careers because of the
interrupted sleep and disruptions to the family. There was an email on
A third advantage of a
laborist for community physicians is an impact on malpractice premiums. At
present there is no evidence that hospitalist care in medicine is associated
with either increased or decreased malpractice rates (17). However, the most common lawsuits against Ob-Gyns
involve fetal distress and delivery in a timely fashion (18). Lawsuits
involving delay of care could be prevented or decreased by having a hospitalist
present 24/7/365.
The current
average rate for malpractice coverage for an obstetrician in
Advantages
for hospitals
There are several potential
advantages for the hospital if a laborist program is developed. There are decreased
costs, decreased cesarean section rates, and decreased length of stay. There is
also the possibility of recruiting physicians to practice at their hospital.
Wachter and Goldman (5) found that in 15 of the
19 studies hospitalists had “significant decreases in both hospital costs
(average decrease 13.4%) and lengths of stay (average decrease 16.6%). They
also found that one study showed a significant decrease in readmission rates.
This observation has also been observed in the obstetrical literature. “It has
been shown that hospitals that provide 24-hour, dedicated in-house physician coverage
show lower cesarean delivery rates” (22). The laborist is available to facilitate
discharges and decrease administrative delays. Often a patient is not ready for
discharge in the morning but she is ready to go later in the day. She stays
over night because the community obstetrician is not available to make hospital
rounds again until the following morning.
Having a laborist program
might decrease elective
inductions. Elective inductions cause increased hospital pre-delivery time and
increased costs. Elective inductions increase c-section risk (23). Community
obstetricians have had increasing induction rates over the past several years.
From 1990 to 1998 induction rates increases from 9.5% to 19.4% (24). In
There is the potential for improved
job satisfaction for nurses. There is a profound nursing shortage affecting
hospitals. Hospital administration must devote resources to recruiting and
retaining nurses. Physician and nurse relationships play an important role in
job satisfaction for nurses (26). The laborist would have a favorable impact on
nurses. Suzanne Wolfe (26) described the hospitalist as a “welcome development”
for nurses. In her study, 98% of the nurses were enthusiastic or very enthusiastic
about the hospitalist system. Hospitalists are available. This translates into
speedier care with less hassle. Instead of trying to adjust to the practice
styles of a multitude of community obstetricians, nurses would only have to
deal with the practice style of a smaller team of obstetricians. Communication
would be improved. Nurses would waste less time trying to track down the
doctors from a practice who might be covering. They would not have to wait on
hold until the doctor comes out of an examining room in his office. They would
not have to try to communicate through OR nurses to a doctor who is scrubbed in
the operating room. Communication could be optimal in a tight knit group that
works together daily. Nursing job satisfaction would be improved and turnover
decreased.
Laborists can provide better continuity
of care for the patient by improving the communication in "shift
hand-offs" between day and evening nursing (26). The prevention of medical
errors by improving communication between health care providers is an important
goal. It is also important for community physicians’ satisfaction with hospital
service (27).
There may also be a new
avenue of opportunity for nurses using nurse practitioners and nurse midwives
in a multidisciplinary team.
There are important legal
implications to the hospital. The most common obstetrical suit against
obstetricians and hospitals is cases that involve fetal distress. These cases
most frequently involve children with cerebral palsy and an allegation that the
clinicians failed to interpret abnormal fetal heart rate tracings in a timely
fashion. One common set-up used by the lawyers is that the physician is not
physically present in the hospital during the patient’s labor. Another common
scenario is that the physician did not come to the hospital immediately when
called contacted by the nurses or other hospital staff. There is frequently no
“paper trail” of the phone calls between the hospital and the doctor. In the
worst cases, doctors and nurses can find themselves pointing fingers at each
other. Under these conditions, the doctor and the hospital can find themselves
as “dueling defendants”, a damaging circumstance for the entire defense team.
Another issue is the 30-minute guideline established by ACOG for “fetal
distress” (9). Even the most dedicated and responsible doctor can be delayed by
traffic (28).
Another area that a laborist
may provide value to the hospital is in physician recruitment. More than 50% of
doctors completing their residency in OB-GYN are female (29). They are less
willing to enter a solo practice or a small group with intense night calls
because of family obligations. They work fewer hours per week than male
physicians (29). A hospital with a laborist program might be more attractive to
them. The more doctors referring to the hospital's delivery services, the more
economy of scale can be realized.
Areas of special consideration
There are five areas of special
consideration in evaluation of the laborist program. There is little written directly
about the roles for obstetricians. However, there is an extensive literature about
the Hospitalist Model for internists and pediatricians. The five areas of
special consideration are as follows:
Ø
Acceptance by Physicians
Ø
Acceptance by Patients
Ø
Economics
Ø
Ethics
Ø
Medical Education
- Acceptance
by Physicians
Traditionally, in ob-gyn practice the doctor patient relationship is treasured. Today patient loyalty is not the expected norm and it is understood that patients will go where their insurance dictates. Doctors are also more mobile and likely to explore more than one practice setting during their careers. Economically and emotionally, it is no longer feasible or expected for most doctors to assume sole responsibility for all aspects of their patients’ medical care.
This is also true in the other areas of primary care. Fernandez et al (30) found that “primary care physicians have generally favorable perceptions of hospitalist’ effect on patients and their own practice satisfaction especially in voluntary hospitalist systems that decrease the workload of primary care physicians and so not threaten their income.”
61% of respondents in a Medical Economics survey voluntarily refer their patients to hospitalists (31). They also found that 81% of physicians favor the use of hospitalists.
Fred Leiberman, MD (32), an
internist, reported “As for my own income, I thought it would suffer, but it
has hasn’t. In fact, my bottom line has improved about 10 per cent since we
started using hospitalists. A key reason, I believe, is productivity. I can
spend more time seeing patients in the office and being reimbursed for that
time.” He also says, “For me personally, the change has been well worth making.
I have more time with my family, no more weekend rounds, and no calls from the
hospital at
On the other hand, hospitalist care isn’t for everyone. Doctors fear losing their special relationship with patients. Others are concerned about turning their patients over to physicians who do not know them. Others like the rounds in the hospital where there is social contact with other doctors and nurses. Many are concerned about losing their clinical skills. There is also a perceived loss of stature when medical practice is confined to the office. Doctors feel as if they are less complete physicians. (31)
Even though hospitalist work is not appealing to many doctors, the momentum is gaining. Currently there are two unfilled jobs for every hospitalist working in the field (33).
·
Acceptance by Patients
“The percent of physicians in solo practice continues to decline, from 39% in 1991 to 29% in 1998 (34). Patients are already prepared to be delivered by someone other than their doctor because 71% of ob-gyns are not solo practitioners (34). Even if a doctor is in solo practice, most physicians have associates with whom they share call coverage.
When the hospitalist
movement began, doctors worried that patients would not accept the hospitalist
model because they were accustomed to their primary care doctor providing all
their care. Patient surveys have shown high levels of satisfaction for
hospitalist care. Patients are willing to trade familiarity for availability (5).
·
Economics
Childbirth
is big business. The following statistics are from the American Journal of
Public Health (35). In 1989, payments for maternity and infant care were
estimated to be $24.4 billion, or about $6250 per mother-infant pair. $1.6 billion of uncompensated care hospital
services was provided. Another $0.8 billion of physicians’ obstetrical services
were uncompensated. As the cost of health care continues to increase, new ways
of providing care are needed. New ways of paying for care is also needed.
Coffman and Rubdall (36) did a meta-analysis of 21 studies on the sources of
funding for hospitalist programs. Patients treated by hospitalists had lower
hospital costs or changes. The reductions in resource use were achieved by increasing
throughput (reducing length of stay) or by decreasing service intensity. They
concluded that hospitalists reduce resource use but do not affect quality of
care or patient, family or provider satisfaction.
In
the future, many trends will impact the economics of obstetrical care. These
included technologic changes in treatment, shorter in-patient stays, more
efficient use of hospital stays, Medicaid eligibility expansions, and universal
health insurance to reduce bad debt and charity care. There is a role for a
laborist is these areas.
·
Ethics
The Hospitalist Model is different from the
traditional patient-doctor relationship. The traditional model is prized for
its ethical protection of the patient based in confidentiality, shared decision
making and respect for autonomy. Hospitalists introduce a purposeful disruption
in the traditional relationship, which threatens these precautions and produces
ethical concerns. Pantilat
et al (37) addressed these ethical issues. There must be cooperation between the
community obstetrician and the laborist
regarding patient confidentiality. The laborist must respect the individual’s
values. There is a role for advanced directives especially around the
resuscitation of premature infants and infants with known anomalies. There must
be clear channels for communication and clarification between the patient, the
family, the laborist, and the community obstetrician. A collaborative consensus
will need to be reached for practice management issues such as confidentiality
and the reporting of test results, lethal fetal anomalies and cases of medical
futility, end of life decisions, patient choice and the maternal-fetal
relationship.
- Medical
Education
The
development of the hospitalist model has raised some concerns about medical
education. Whitcomb and Nelson (38) summarized
the pros and cons. Review of the literature found two studies showing overall
house staff satisfaction was comparable to the traditional arrangement. A third
study showed marked improvement in supervision of procedures which makes sense
considering the availability of the hospitalist compared to traditional
attendings. They addressed the concern that hospitalist might usurp the
autonomy of residents because of their availability. This fear was unsupported by
the data.
In considering the future of obstetrics, recruitment to
the specialty is way down. Another reason medical students are not attracted to
the specialty of OB-GYN is the issues relating to malpractice (39).
Conclusion
There
are many opportunities for investigation as the laborist movement spreads.
There is the research opportunity to study standardization of obstetrical care.
It will improve the ability to conduct clinical trials and to allow multicenter
data collection on rare complications and diseases. It will allow for a more
rapid spread of incremental
improvements in technology.
Adoption of a hospitalist model
could help obstetricians struggling in the current economic environment.
Laborists could improve revenue by allowing physicians to maximize outpatient
revenue and decrease non-productive waiting times. Laborists could decrease
malpractice risk by improving safety in the hospital. Decreased risk should be
translated into lower premiums. By improving life style, laborists might make
the field more attractive to students and may improve the burnout of practicing obstetricians. Laborist support
could improve established physicians' ability to recruit associates into
practices improving lifestyle and allowing for economies of scale.
The Laborist will be good for
patients. Women will be cared for by experts who can focus their attention
undistracted. Safety in childbirth will be improved.
The Laborist will be good for
hospitals. There will be increased efficiency and decreased induction. There
will be a decreased threat of malpractice. There will be improvement in nursing
satisfaction and retention.
The time for change is here. An
obstetrical hospitalist will be a good thing for all the stakeholders who care
for
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