Division of Labor
There's a new doc in town. But mom probably won't meet this obstetrician until her labor pains start
Jolene Taylor was 21 weeks pregnant with her first child when she found herself in a pickle. Her obstetrician, whom she'd been seeing for routine care for more than four years, decided to stop delivering babies. Meantime, the high-risk-pregnancy specialist she'd also been seeing as a precaution for a potential virus exposure--she's a registered nurse--didn't practice at her nearby hospital, Legacy Salmon Creek, in Vancouver, Wash. So after talking with her specialist, Taylor, 27, opted to have her baby delivered by a new breed of obstetrician called a "laborist" or, as her hospital calls it, an "OB hospitalist." Both job titles mean the same thing: an obstetrician who works exclusively in the hospital, keeping watch over women in labor and performing deliveries.
Separating the prenatal care process and the actual birth is a smart solution for doctors who are frustrated by high malpractice premiums and burned out by the demanding lifestyle. Like other hospital-based doctors--emergency room physicians come to mind--OB hospitalists work in shifts, covering the maternity ward as well as dealing with emergency obstetric cases. Since they are employed by the hospital, their malpractice premiums are covered, and there are no back-office expenses like those of an outside practice. Laborists can also be a plus for the new mother, since the limited hours keep them fresher and less prone to errors, and their job description focuses on attending to her during labor. Sounds great, but birth is not just a medical procedure. Having a baby is also one of the most precious moments of a woman's life. It might be tough for some women to entrust their special day to someone they've just met.
A handful of hospitals have had laborists on staff for about five years. But the idea really began to percolate in 2003, when Louis Weinstein, now chairman of obstetrics and gynecology at Philadelphia's Thomas Jefferson University, proposed the idea in an editorial in the American Journal of Obstetrics and Gynecology . Weinstein thought laborists could help solve one of the profession's most vexing problems: grueling daily schedules. A doctor may end up driving across town several times a day to see patients at different hospitals and often gets up in the middle of the night to deliver a child. The resulting fatigue can have many consequences. "When things go wrong in labor and delivery, they go wrong exceedingly quickly," says Weinstein. "If you aren't responsive in minutes, the baby may be damaged or die and mom may die. And if I'm in the office seeing patients and a nurse calls me, by the time I get there it may take me 20 minutes." Because of the hours and stress, burnout among obstetricians is common. Working 70 or 80 hours a week, Weinstein says, "doesn't make sense for my health or for patients' health." And improved safety, he says, will lead to lower malpractice insurance costs.
Having a life. Laborists devote their full time and attention to mothers in labor, without worrying about an office full of patients. It also may be a better deal for private obstetricians, who can opt to hand over labor supervision and the delivery--although many OBs still prefer to deliver their patients' babies. Both kinds of OBs can have a life, a key factor for doctors now entering the profession. "Young people are smarter than we were," says Duncan Neilson, an obstetrician and chief of women's services at Legacy Health System, which owns Legacy Salmon Creek. "The idea that a person's work would be totally dominated by professional commitments and would show complete disregard for family isn't holding anymore."
That sounded good to Andrew Vincent, one of the obstetricians recently hired by Legacy. He spent 11 years in private practice, most of it with just one partner. "I was seeing patients from 8 to 5, then making rounds, then on call at night." Vincent had little personal time, but that has all changed. "I can make plans to go to dinner or a movie," he says, and he can spend more time with his wife and three children.
About 10 hospital systems, including Washington Hospital Healthcare System in California and Parkridge Medical Center in Tennessee, currently employ (or are about to employ) laborists. The president of the American College of Obstetrics and Gynecology, Michael Mennuti, said in his inaugural speech in May that the system might be a solution to the work-life balance concerns that have burned out older doctors and sent many younger ones into other specialties. When Legacy set out to hire four OB hospitalists before its August opening, it got 60 applications within the first week from midcareer doctors eager for a change. "Hospitalists and emergency department physicians have been the pioneers, and this will follow that model," says Kurt Mosley, vice president of business development for healthcare staffing company MHA Group. "It's progressed past the flavor of the month, it's successful in key areas, and word is getting out." Neilson says private obstetricians were initially suspicious, but that hurdle was cleared when they learned they could still do deliveries if they wanted to.
Continuity. Of course, it's not all about the doctors. Traditionally, babies were delivered by the doctors who provided their mothers with prenatal care. And some women still feel very strongly about that relationship. "Most families and women see pregnancy as a very, very special time for the family and the pregnant mother" and want to share the experience with a trusted clinician that they know, says Robert Barbieri, chief of obstetrics and gynecology at Brigham and Women's Hospital in Boston. He thinks a move toward defined shifts is a good idea but because of that desire for an ongoing doctor-patient relationship, he isn't sure laborists are the best way to reduce long hours.
That was how Agnes Charrel-Berthillier, 32, felt when she was pregnant for the first time. She picked the northern California hospital where her son was born because it had a midwife program that meant the same person would be by her side through labor and delivery. Laborists working in shifts, Charrel-Berthillier says, couldn't guarantee that continuity. She says the system sounds like it "is about making things better for doctors" rather than for patients, and she plans to use the same midwife for the birth of her second child. And indeed, some experts note midwives, backed up by specialists in case of emergency, could fill the laborist role and even provide seamless prenatal care.
Yet hospitals say most women don't blink at the laborist model. Since many doctors belong to large practices, women have long been accustomed to the idea that an unfamiliar doctor may be the one to deliver their baby. "There's rarely a complaint," says Ruth Shaber, director of women's health services for the northern California region of Kaiser Permanente, the managed-care provider that for decades has told women that the doctor providing prenatal care probably won't deliver the baby. At Kaiser, staff OBs take shifts in labor and delivery but unlike laborists also maintain outside practices. "In the throes of labor, you really want someone who is there, completely committed, and not distracted by other things," says Shaber. Judy Rhyne, chief nursing officer at Parkridge East Hospital in Chattanooga, Tenn., which has had OB hospitalists for four years, says it comes down to quality of care. "It satisfies patients, physicians, and nurses to know that the doctor is there to help them triage."
As for Taylor, her little one was born earlier this month, delivered by the OB hospitalist on duty. He "was there the whole time, stopped by many times, checked me, checked up on things, even the next day stopped in a few times," says Taylor. And now, Mom and baby Evan are doing fine.
This story appears in the December 5, 2005 print edition of U.S. News & World Report.