Expert Commentary

The laborists are here, but can they thrive in US hospitals?

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So new is this model that hard data on its value are wanting. But those who have firsthand experience report important benefits.


 

References

Quick Quotes

“The vast majority of patients would be relieved to realize that there is someone there for an emergent situation.”—ANDY BROWN, MD

“Hospitals are offering $100 an hour for call and nobody will take them up on it.”—LOUIS WEINSTEIN, MD

At Shawnee Mission Medical Center in Kansas City, Kansas, a delivery early this year placed the 3-day-old laborist program squarely in the spotlight.

The uterus ruptured in a patient who had placenta previa. She required immediate intervention, but her private ObGyn was 25 minutes away. A laborist stepped in and performed C-section within 10 minutes, while the private physician was still en route.

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“And our neonatologist said, had we had to wait the extra 5 or 10 minutes it took for that doc to arrive and get started, there would have been a much worse outcome for that baby because it had lost 40% of its blood volume,” says Deb Ohnoutka, administrative director of women’s and children’s services.

Not all interventions involving a laborist are as dramatic, but the laborist, or OB hospitalist, model—in which a hospital employs board-certified ObGyns for 24/7 coverage of labor and delivery—is gradually taking hold.

Because the model is new, there are no concrete data on exactly how many hospitals employ laborists or whether safety has improved as a result. To get an idea of how this model is faring, OBG Management interviewed a number of program administrators and laborists, whose comments are woven into this article. They describe diminishing pressures on community ObGyns, improved job satisfaction among laborists, greater patient safety, and other benefits.

Whence the inspiration?

It all started in 2003, when Louis Weinstein, MD, now chairman of obstetrics and gynecology at Jefferson Medical College in Philadelphia, penned an opinion piece for the American Journal of Obstetrics and Gynecology on the need for a new way of practicing obstetrics.1 Weinstein cited some of the pressures assailing the profession.

“The desire to control one’s personal life, coupled with an apparent decrease in aggregate productivity and the increasing cost of professional liability insurance,” he wrote, “have the potential to lead to a decrease in the available obstetric work force within the next decade.”1

Weinstein now says that, in fact, roughly “30% of physicians will stop working in the next 7 years. People say there’s a shortage of physicians, but it’s really a shortage of working physicians. It’s because of physician dissatisfaction.”

The solution?

Weinstein points to the success of the hospitalist model, which originated in 1996. He proposed a similar paradigm for obstetrics.

“I just sat down and worked out this thing called the laborist movement. When you look at the hospitalist model, their safety is way up” and job satisfaction is improved, he says, noting that he expects the laborist model to have a similar impact.

It took a while for Weinstein’s proposal to percolate through the specialty.

“I wrote about it in 2003 and for 2 years nobody even talked to me about it,” he says. It wasn’t until 2005 that the discussion began.

People began to acknowledge that a significant change in practice was needed to improve quality of care, increase safety for the patient and her fetus, and reduce medical negligence actions for hospitals.

“The way we practice obstetrics is insane,” says Weinstein. “People can’t work like they’re working.”

“Why is there a laborist, Mommy?” Because the hospitalist model works so well…

Louis Weinstein, MD, chairman of obstetrics and gynecology at Jefferson Medical College in Philadelphia, proposed the laborist model in 2003.1 Among the justifications he gave for the new model were the following observations about the hospitalist model:

  • “The reasons for development of the hospitalist model included an increase in the serious nature of disease in hospitalized patients, the need for physicians to spend more time in their offices with increasing outpatient volume, the decrease in inpatient admissions, the difficulty for most practitioners to stay at the cutting edge of medical care, and the documented fact that those who do something repetitively do it better and with less expense.”1
  • “Studies have demonstrated that patient satisfaction has been preserved by using a hospitalist and that significant reductions in resource utilization have occurred while good clinical outcomes were maintained.”1-4
  • “An interesting analysis of hospitalists themselves demonstrated a high level of job satisfaction, low levels of burnout, and a long-term commitment to remaining in this field.”1,5
  • “A concern frequently expressed about the hospitalist is the disruption of care when the hospitalist becomes responsible for the hospitalized patient. Evidence exists among medical patients that they are very satisfied with the care of the hospitalist because of immediate physician availability, increase in time to talk with the patient and family, and expertise in patient management.”1,6

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