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Debating the laborist model of care

Boon to obstetric outcomes or bellwether of lifestyle choice?


In this first installment of Contemporary OB/GYN’s Point/Counterpoint department, two physicians discuss the advantages and disadvantages of the laborist (or “hospitalist”) model of care. What are the pros and cons for ob/gyns and their patients?

PRO by Karenmarie K. Meyer, MD, FCOG 

It’s 2 pm, you had 2 deliveries after midnight last night, and you are still in scrubs. You’ve been in the office since 10 am. You are 45 minutes behind and have 15 patients left to see. A call comes from the hospital labor and delivery department informing you that a term VBAC patient just arrived in labor and you need to be present. You will have to cancel the rest of your office patients and deal with all that goes along with doing so. You have to call home to say that once again you won’t be coming home for dinner. It’s a scenario familiar to most ob/gyns.

Now consider this scenario, which you would experience as an ob/gyn practicing at one of the more than 185 hospitals that have ob/gyn hospitalists available. You can sign out of your hospital practice to a board-certified, experienced, emergency-ready obstetrician who can admit and manage your patient for you. You can finish your office appointments, go home for a family meal, take a needed nap, and then go to the hospital and take back management of your patient’s labor, more alert and more focused than you otherwise might have been.

Ob/gyn hospitalists (also known as “laborists”) are available 24/7 to support and assist private physicians, nursing staff, midlevel caregivers, and patients. We are immediately present and respond to obstetric and gynecologic emergencies. We can take on unassigned patients, monitor tracing strips, perform triage, and quickly facilitate the transfer of patients to higher-level units when needed.

Our unique position enables us to provide additional nursing education. Our constant presence on the floor gives residents access to continuous mentoring. This presence also means we encourage standardization and best practices while assuming leadership roles in system-wide quality improvement initiatives. All this increases patient safety and satisfaction.

In many situations, we work closely with maternal-fetal medicine (MFM) specialists to deal with complicated hospitalized patients who need immediate attention—for example, those with preterm labor, preterm premature rupture of membranes (PPROM), or hypertensive crisis.

Presently, the website ObGynHospitalist.com has 1245 registered members and recently conducted a survey that showed that due to a shortage of in-house MFM specialists, between 45% and 55% of ob/gyn hospitalists act as perinatologists’ extenders.

Providing immediate therapy and improved response time decreases bad outcomes and medical liability and increases both patient satisfaction and maternal and neonatal outcomes. For these reasons, ob/gyn hospitalists have gained acceptance among nurses, private physicians, hospitals, and patients.

The American College of Obstetricians and Gynecologists supports the continued development of the ob/gyn hospitalist.1 The Society for Maternal-Fetal Medicine (SMFM) also supports laborists’ ongoing and immediate evaluation and care of high-risk obstetric patients.

The research is catching up. The Society of OB/GYN Hospitalists (SOGH) has more than 150 members and is growing. It now has a Research, Education, and Safety Committee that is actively compiling data about the model and its impact on inpatient care and quality.

A study called “Does the laborist model improve obstetric outcomes?” showed that “using the laborist model resulted in 15% fewer labor inductions, reduced maternal length of stay and a significant reduction in preterm delivery . . . and decreased term NICU admissions.”2

Ob/gyn hospitalists are experienced immediate responders, educators, leaders, and perinatologist extenders who improve obstetric outcomes. I believe that the question will soon shift from, “Why have an ob/gyn hospitalist program?” to the demand, “Why don’t we have one?”

REFERENCES

1. Committee opinion no. 459: the obstetric-gynecologic hospitalist. Obstet Gynecol. 2010;116(1):237-239.

2. Srinivas S, Macheras M, Small D,
Lorch S. Does the laborist model improve obstetric outcomes? Paper presented at: Society for Maternal-Fetal Medicine Annual Meeting; February 11-16, 2013; San Francisco, CA. Abstract 79.

Dr. Meyer is an ob/gyn hospitalist at MacNeal Hospital, Berwyn, Illinois, an ob/gyn hospitalist and assistant professor of clinical obstetrics and gynecology at the University of Illinois, Rockford, and a clinical instructor of obstetrics and gynecology at Northwestern University School of Medicine, Chicago, Illinois. She is currently president of the Society of OB/GYN Hospitalists. She reports that she has no conflict of interest to disclose with respect to the content of this article.

CON by Edward R. Yeomans, MD

A catchy new acronym is familiar to the current generation of medical students: EROAD. It stands for emergency medicine, radiology, ophthalmology, anesthesiology, and dermatology. Aspiring physicians are attracted to these specialties for a variety of reasons, chief among which are lifestyle and remuneration. Is it conceivable that the “O” in that acronym could represent “obstetrics”?

Before expanding my antilaborist position, let me point out that the gynecology half of our specialty will be prone to disuse atrophy among laborists: “Young” laborists won’t have enough cases for their board examinations and “old” laborists will not be able to maintain their hysterectomy skills or privileges. But I digress.

The prospect of labor and delivery management being taught to residents by shift workers is anathema. Does the teacher’s shift end as the patient enters the second stage of labor with a fetus in occiput posterior position?

As a young and impressionable intern back in 1980, I watched my chief resident stay with a desperately ill parturient patient for 3 days, never leaving her bedside. His dedication inspired me; his unwavering commitment to the patient and his illustration of caring for a woman he barely knew helped set the bar for my definition of an obstetrician, a hallowed term that is tarnished by the substitution of “laborist.”

I object to the adverse effect on the doctor-patient relationship, the raison d’être for the properly motivated young physician to enter the field of obstetrics and gynecology in the first place.

The motivation should not be the lifestyle but the longitudinal care of women antepartum, intrapartum, and postpartum; during a second pregnancy and perhaps a third; providing contraception and minor or major surgery; and through menopause.

The practice of obstetrics was never meant to be cross-sectional. According to the American College of Obstetricians and Gynecologists,1 the laborist model “has the potential to achieve benefits for the obstetrician-gynecologist given the varied demands of the specialty.” I submit that these demands are not new. They were met by generations of our predecessors in the interests of their patients.

Obstetrics is not a “lifestyle” specialty and therefore not a candidate for the “O” in EROAD. Patients place trust in their obstetricians as a result of short but satisfying antepartum visits. Whether a laborist could prove worthy of that trust is for pregnant women to decide.

REFERENCE

1. Committee opinion no. 459: the obstetric-gynecologic hospitalist. Obstet Gynecol. 2010;116(1):237-239.

Dr. Yeomans is department chair of obstetrics and gynecology at Texas Tech University Health Sciences Center, Lubbock. He is also professor of clinical obstetrics and gynecology and a maternal-fetal medicine specialist. He reports that he has no conflict of interest to disclose with respect to the content of this article.

Point/Counterpoint serves to feature current, provocative topics in obstetrics and gynecology and present opposing viewpoints. The contributors to this series have been specifically selected for their expertise as well as their willingness to take a position. The purpose is to create a forum for respectful debate, knowing well that the discipline of medicine is as much an art as a science.

Laurie J. McKenzie, MD, Section Editor, is director of oncofertility, Houston IVF, and Director, Houston Oncofertility Preservation and Education (H.O.P.E.).

In the nearly 40 years since the Yuzpe method was first described, options for emergency contraception—including over-the-counter availability—have expanded. Yet misunderstandings about these methods still exist.

This is an unusual case. Litigation doesn’t usually take decades, but this case went through multiple plaintiffs’ attorneys and sat quiet on the court’s docket until the court was clearing old cases and reexamined it.

Having unprotected sex is not the only impetus for use of emergency contraception (EC) among US women of reproductive age, according to data from a recent study by the Centers for Disease Control and Prevention (CDC). Nearly half the women represented in the National Survey of Family Growth (NSFG) said they turned to EC because of fear of contraceptive failure.

Women whose pregnancies are complicated by hyperemesis gravidarum in the second trimester are at a much higher risk of placental dysfunction disorders such as placental abruption and small-for-gestational age (SGA) babies, according to a study appearing in the January 30, 2013, issue of BJOG: An International Journal of Obstetrics and Gynaecology.

On October 24, 2012, the Advisory Committee on Immunization Practices (ACIP) of the CDC voted to recommend administering the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) to pregnant women with every pregnancy, regardless of the women’s previous Tdap history.


Dr. Daniel Strickland
The laborist model, in its various forms, is inevitable in many locations. Young physicians, especially women with multiple career obligations, are not willing to make the physical and emotional sacrifices that Dr. Yeomans and I did back in the Jurassic period. I also believe that it is unsafe (for doc and patient) to balance night call, a busy clinic, and continued labor deck responsibilities. Some practices can work these problems out, but only if they are adequately staffed - and therein lies the rub. From 1995 (through 2010) I maintained a Gyn only practice but continued to work actively as a locums physician (and still do). In most situations, a locums is basically an OBG hospitalist, and in several cases I was given that "title." Dr. Yeomans is spot on to suggest that inexperienced OBGs should *not* be Laborists (nor do locums). Rarely is there anyone to assist you with problems except a general surgeon or a telephone consultant. 99% of the time you are on your own. It is not for the faint of heart or confidence. :-) He is also correct that a locums or Laborist does little gyn during his/her shift. It is pretty much D&Cs and scopes. But how many abdominal hysterectomies does one need to do to maintain competence? In my 17 years of locums practice I have needed to perform only 1 hysterectomy, and that was for menorrhagia intractable to medical therapy and in retrospect I probably could have stopped that with a balloon. But hospital credentialing policies will need to be adapted to the situation in which an OBG Hospitalist might not maintain as many cases as the bylaws require. But there are many ways to insure competence without violating JCAHCO rules or compromising patient care. I also agree that Laborists are not optimal for resident training. But are they really any different from community hospital residencies, in which local private docs do most of the "teaching?" In conclusion, Dr. Yeomans is right, in the ideal world. In the real world, Laborist use will continue to grow. Full disclosure: I was one of Dr. Yeomans' Chief Residents, but not the one of which he spoke. :-)
Mar 25, 2013
Dr. Dominick
We chose another option in our hospital: with the support of nearly all of our private practice physicians, and an administration willing to try a different approach, we created a model of 24 hr laborist coverage that is staffed by the private docs on a rotating basis. By doing this, we have seen a reduction of risk, and a true partnering with the hospital as well as our colleagues. We are able to keep our gyn skills up, and many of us are certified in robotics as well as urogyn procedures. It has thus far been the best of both worlds, and is about 6 years old. Should the practice of medicine change, we are in position to change with it. I urge my colleagues to consider this option.
Mar 22, 2013
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