Debating the laborist model of care

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.

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.

NEXT: CON by Edward R. Yeomans, MD >>

CON by Edward R. Yeomans, MD

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.

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.

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.).