Maintaining excellence in obstetrics and gynecology

Faced with dramatic changes in the practice and financing of medicine during the past 2 decades, clinicians, educators, and researchers have struggled to adapt. Obstetrics and gynecology has seen an increased emphasis on subspecialization, without equal emphasis on enhancing women’s care. The workforce also has changed, with the rise of shift work. Ob/gyn trainees must master-and educators must respond to-a rapidly expanding scope of knowledge. This will require redesign of our resident/fellowship education programs.

Research in our specialty is suffering from insufficient funding and emphasis on funding large randomized trials rather than smaller translational studies, which are the seeds of innovation. Compounding the problem, faculty are increasingly being asked to generate more clinical income.

The US healthcare system faces many serious challenges requiring solutions that combine political, economic, and societal input. The recent presidential election adds a further layer of uncertainty.

Here we challenge our specialty to address its own shortcomings in clinical practice, education, and research. This call to action grew out of presentations at the 2015 annual meeting of the Yale Obstetrics and Gynecological Society (YOGS), a group whose members include current and past medical school deans, departmental chairs, division chiefs, past presidents of our major professional societies, and members of the National Academy of Medicine.

Contemporary US obstetrics and gynecology is awash in paradox. Preterm neonates are surviving at ever-earlier gestational ages^1,2 and preterm birth (PTB) rates have modestly declined during the past decade but they still exceed those of other western nations.³

US maternal mortality rates are low by historical standards but higher than in other developed countries,⁴ and rose from 7.2/100,000 live births in 1987 to 17.8/100,000 in 2011.⁵ Cardiovascular disease and cardiomyopathy together account for a quarter of all maternal deaths, likely reflecting survival of infants with congenital heart disease to adulthood, an aging pregnant population with more comorbidities, and inconsistent access to preconception care.

Recent public health triumphs such as a decrease in teen pregnancies to an all-time low of 26.5 per 1000 women³, declining elective terminations of pregnancy⁶, and expanded access to reversible contraception⁷ are threatened by political pressure to limit or roll back access to contraception.⁸

In the last decade, hysterectomy rates have decreased by 40%⁹ and the cesarean delivery rate has risen to 32%.¹⁰ The latter has resulted in increased rates of placenta accreta^11,12 and cesarean scar pregnancies¹³- trends that could exacerbate maternal morbidity and mortality and do increase healthcare costs.

These examples reflect both achievements and challenges in our field. The latter are particularly sobering given that our specialty’s very identify rests on safeguarding women’s general and reproductive health.

1. Subspecialization

The specialty has wrestled for decades with the balance between its essential function as a primary care discipline (an ob/gyn may be the only physician a woman 20–50 years of age will see regularly), and a growing emphasis on the need for subspecialty expertise (gynecologic oncology, maternal-fetal medicine, reproductive endocrinology and infertility, urogynecology, and family planning). Currently, about 1 in 3 ob/gyns are practicing as subspecialists but, especially in large urban training programs, the status of the career path of the specialist (alternatively defined as the generalist) in the field has been downplayed.

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Several trends have conspired to fuel this development. First, in our fee-for-service paradigm, the bigger financial rewards associated with activities generated by subspecialists lure many young ob/gyns into those careers. Secondly, in academic training centers where federal grant funding and state support have been stagnant for years, departments have increasingly depended upon clinical earnings to survive; ergo, the financial necessity of hiring disproportionately more subspecialists who influence the direction of residents into subspecialties. However, specialists are essential to women’s healthcare as they serve as primary care providers for many women in their reproductive years. They also provide subspecialty-type care for women who live far from tertiary care hospitals, where subspecialists are concentrated.

Moreover, without the specialist, who would provide basic ob/gyn care for these women? Family practitioners are increasingly eschewing obstetrics. Nurse practitioners, physician assistants, or certified nurse-midwives can provide some such care, but need well-trained general ob/gyns to handle pregnancy complications, gynecologic consultations, and surgery. The generalist can also provide preventive care to prevent obesity and metabolic syndrome, assist in family planning, and manage menopause, especially in a team-based care method.

In rural, exurban, and many suburban areas, absence of a seasoned specialist skilled in labor management and operative delivery may increase cesarean delivery rates. The importance of the annual well-woman visit-a catalyst for preventive medicine-and the management of psychosocial issues could also be compromised.

NEXT: Student debt and excessive documentation

2. Student debt

Student debt is having a major impact on the medical profession. The ability to quickly pay off student loans likely plays a role in students’ career choices. The median medical school debt is now $160,000 for public and $190,000 for private schools.¹⁴ Students entering training for primary care, with its inherently lower salaries, have the worst tuition-to-annual-earnings ratio, but ob/gyn residents are not far behind.^15,16

In addition, young physicians with high debt loads who choose to practice ob/gyn may be drawn to more lucrative subspecialties rather than generalist careers.

3. Excessive documentation

Excessive documentation, a challenge faced by the entire medical profession, is contributing to ob/gyns leaving the workforce in mid-career or taking early retirement.¹⁷

Regulations imposed by the Centers for Medicare & Medicaid Services (CMS) and by commercial payers increase the time required to deal with authorization and increasingly complicated coding documentation. Contemporary electronic health records (EHRs) have been fashioned to link together patient data, order entry, coding, compliance, charge capture, and billing, and to meet regulations to ensure thoroughness of care. However, the need to be “comprehensive” is often at odds with the equally important goal of simplification, resulting in EHR products that challenge even the most computer-savvy provider.

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One study reported that emergency room doctors can spend 43% of their time entering data (requiring as many as 4000 mouse clicks per 10-hour shift), versus 28% talking to patients.¹⁸

4. High professional liability insurance costs

An ob/gyn is the 7th-most-likely specialist to be a defendant in a professional liability suit, resulting in elevated liability insurance premiums.¹⁹ This heightens practice overhead and contributes to the overall cost of medical care. Defensive medicine further escalates cost. A 2012 survey¹⁷ showed that 15% of obstetricians increased their cesarean delivery rate, 12% left private practice, and 4% moved to another state because of fear of possible litigation. That survey also indicated that the professional liability cloud has driven 1 in 20 ob/gyns out of active obstetrical practice altogether.

This adversarial aspect of the work environment also leads to physician burnout, further exacerbating shortages.

Solutions

1. Improve specialist training

The focus of all ob/gyn training programs should be to create more “all-pro” specialists. Specialists should be hired to teach and to provide clinical care. Academic medical centers also could establish a nontraditional faculty model to populate affiliated hospitals. In that model, nontraditional faculty would focus primarily on patient care along with a cadre of traditional academic faculty appointees.^20,21

Nontraditional faculty members help maintain clinical volume and revenue, allowing traditional faculty more time to pursue academic activities. Additional support would be needed from health systems or hospitals that benefit from revenue generated by these physicians.

2. Recycle expertise

Another source of clinical expertise is the large cohort of retired or soon-to-be-retired ob/gyns. As part-time faculty members, they could educate students/residents while providing clinical expertise developed through years of experience. Strategies to minimize professional liability insurance costs should be pursued to retain this vital intellectual capital without draining department funds needed for research.

NEXT: Improving patient safety

3. Lessen student debt

Since tuition accounts for only 4%–6% of total medical school financial support, some academic medical centers could continue to function without it, and most could afford to freeze tuition for several years.

Another debt reduction opportunity is collaboration with the Accreditation Council for Graduate Medical Education (ACGME), state Medicaid agencies, and Public Health Service agencies to develop programs that allow graduating residents to work off debt by working in underserved communities, an ob/gyn “Peace Corps.”²² For example, for each year of such service post-graduation, a certain portion of a student’s medical school debt could be forgiven by being paid through state Medicaid funds.

4. Streamline documentation

EHR changes are needed. Regulators must be more pragmatic, and software designers must rethink and redesign processes that are now tailored for regulatory and insurance compliance rather than for patient care and physician productivity. In addition to simplifying data entry processes, employing scribes to shadow busy ob/gyns and enter data during every patient encounter will provide more “eye-to-eye” time with patients.

5. Improve patient safety

The new Republican administration and Congress may renew efforts at federal tort reform, although it failed to materialize under the Bush administration and is unlikely to be prioritized. In any case, we should focus on avoiding harm by using the best evidence-based medicine available.

Team training, crew resource management, checklists, and evidence-based protocols are now widespread. However, while making EHR systems more user-friendly, the technology should also be used to create patient safety tools such as decision support and enhanced documentation in high-risk settings. The latter could include presenting concrete evidence of surveillance, problem anticipation, proactive and reactive planning and execution, details of outcomes, and assurance that adequate information has been conveyed to the patient.

Next: The big healthcare disappointment

Improved patient record-keeping could be taught through tutorials, video simulations, and hands-on demonstrations, proven methods to enhance patient outcomes and experience.²³ Because “avoidance of harm” is the best defense against liability suits, hospitals, local American College of Obstetricians and Gynecologists districts, and State Perinatal Quality Improvement Programs should focus on developing checklists, tool kits, and EHR decision support tools to prevent adverse outcomes.

References

1. Rysavy MA, Li L, Bell EF, et al. Between-hospital variation in treatment and outcomes in extremely preterm infants. N Engl J Med. 2015;372(19):1801-1811.

2. Mercer B, Milluzzi C, Collin M. Periviable birth at 20 to 26 weeks of gestation: proximate causes, previous obstetric history and recurrence risk. Am J Obstet Gynecol. 2005;193(3 Pt 2):1175-1180.

3. Osterman MJK, Kochanek KD, MacDorman MF, Strobino DM, Guyer B. Annual summary of vital statistics: 2012-2013. Pediatrics. 2015;135(6):1115-1125.

4. Ingraham C. Our maternal mortality rate is a national embarrassment. Washington Post. https://www.washingtonpost.com/news/wonk/wp/2015/11/18/our-maternal-mortality-rate-is-a-national-embarrassment/. Published 2015.

5. Robeznieks A. U.S. has highest maternal death rate among developed countries. May 6 . http://www.modernhealthcare.com/article/20150506/NEWS/150509941. Published 2015. Accessed July 18, 2015.

6. Abortion. http://www.cdc.gov/reproductivehealth/data_stats/#Abortion. Accessed July 18, 2015.

7. Secura GM, Madden T, McNicholas C, et al. Provision of no-cost, long-acting contraception and teenage pregnancy. N Engl J Med. 2014;371(14):1316-1323..

8. Pear R. Passions Flare as House Debates Birth Control Rule. http://www.nytimes.com/2012/02/17/us/politics/birth-control-coverage-rule-debated-at-house-hearing.html?_r=0. Published 2012.

9. Wright JD, Herzog TJ, Tsui J, et al. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol. 2013;122(2 Pt 1):233-241.

10. Changes in Cesarean Delivery Rates by Gestational Age: United States. NCHS Data Brief No. 124 . http://www.cdc.gov/nchs/data/databriefs/db124.htm#x2013;2011%3C/a%3E. Published 2013. Accessed July 18, 2015.

11. Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol. 1997;177(1):210-214.

12. Wu S, Kocherginsky M, Hibbard JU. Abnormal placentation: twenty-year analysis. Am J Obstet Gynecol. 2005;192(5):1458-1461.

13. Timor-Tritsch IE, Monteagudo A. Unforeseen consequences of the increasing rate of cesarean deliveries: early placenta accreta and cesarean scar pregnancy. A review. Am J Obstet Gynecol. 2012;207(1):14-29.

14. Asch DA, Nicholson S, Vujicic M. Are We in a Medical Education Bubble Market? http://dx.doi.org/101056/NEJMp1310778. 2013.

15. Medical Student Education: Debt, Costs, and Loan Repayment Fact Card. 2014.

16. Grayson MS, Newton DA, Thompson LF. Payback time: the associations of debt and income with medical student career choice. Med Educ. 2012;46(10):983-991.

17. Medical Liability Climate Hurts Patients and Ob-Gyns. ACOG Sept 5. http://www.acog.org/About-ACOG/News-Room/News-Releases/2012/Medical-Liability-Climate-Hurts-Patients-and-Ob-Gyns. Published 2012. Accessed June 28, 2016.

18. Hill RG, Sears LM, Melanson SW. 4000 clicks: a productivity analysis of electronic medical records in a community hospital ED. Am J Emerg Med. 2013;31(11):1591-1594.

19. Jena AB, Seabury S, Lakdawalla D, Chandra A. Malpractice Risk According to Physician Specialty. http://dx.doi.org/101056/NEJMsa1012370. 2011.

20. Medicine I of. Graduate Medical Education That Meets the Nation’s Health Needs. Washington, D.C.: National Academies Press; 2014.

21. Reece EA, Chrencik RA, Miller ED. Fully aligned academic health centers: a model for 21st-century job creation and sustainable economic growth. Acad Med. 2012;87(7):982-987.

22. Gallin EK, Bond E, Califf RM, et al. Forging stronger partnerships between academic health centers and patient-driven organizations. Acad Med. 2013;88(9):1220-1224.

23. Quinn MA, Kats AM, Kleinman K, et al. The Relationship Between Electronic Health Records and Malpractice Claims. Arch Intern Med. 2012;172(15):505-516.