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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 

    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.

    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.

     

    Karenmarie K. Meyer, MD, FCOG
    Dr. Meyer is an ob/gyn hospitalist at MacNeal Hospital, Berwyn, Illinois, an ob/gyn hospitalist and assistant professor of clinical ...
    Edward R. Yeomans, MD
    Dr. Yeomans is department chair of obstetrics and gynecology at Texas Tech University Health Sciences Center, Lubbock. He is also ...

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    • 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. :-)
    • 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.

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