“THE LABORISTS ARE HERE, BUT CAN THEY THRIVE IN US HOSPITALS?” BY JANELLE YATES (AUGUST)
I do not agree with the comments of Dr. Raksha Joshi, Medical Director of the Monmouth Family Health Center, who was quoted in Ms. Yates’ article as saying that convenience to solo practitioners was a selling point for the laborist program at Monmouth Medical Center. The laborist group at Monmouth Medical Center—a separate entity from Monmouth Family Health Center, Dr. Joshi’s employer—was implemented purely for patient safety. The number of patients in the hospital at any one time was excessive for the resident staffand doctor of the day, with a resident complement totaling eight and more than 4,200 births annually. The laborists are now considered the backup for private practice physicians, providing 24/7 coverage 365 days a year—for which they are compensated by the hospital. (There is cross coverage on an as-needed basis.)
We require the laborist staff (active private practitioners who elected to be part of the laborist group—approximately 30 ObGyns) to:
- be board-certified or board-eligible
- take a risk-management course
- be certified in basic life support, advanced clinical life support, neonatal advanced life support, and advanced life support in obstetrics.
Because the laborist group comprises contracted employees with private practices, hospital employees and faculty such as myself are not allowed to join. Members of the New Jersey Laborist Group, LLC, must adhere to the by-laws of the group or risk removal from it. (These by-laws are separate from those of the hospital.)
As a result of the move to laborists, we have seen:
- a 20% increase in patient volume
- a 50% reduction in cases presented to risk management
- an increase in vaginal birth after cesarean delivery (VBAC), with 78% of attempted VBACs delivered vaginally
- a decrease in NICU admission
- a reduction (to zero) in neonatal death
- a decrease in the C-section rate to 25% (the New Jersey C-section rate is the highest in the United States, at 37%)
- a 1.1% infection rate following C-section
- a rate of third- and fourth-degree laceration that is below the national average
- a decreasing length of stay.
The culture of the program is one of patient safety first and team effort. All patient management adheres to evidence-based protocols that are evaluated, updated, and approved by the staff and monitored by the performance improvement committee.
We are very pleased with the results. I wish to say that, although quality of life has improved for the physicians, the importance of this benefit pales in comparison with the improvement in the environment of safety in which we all now practice.
Robert A. Graebe, MD
Chairman and Residency
Department of Obstetrics and Gynecology
Monmouth Medical Center
Long Branch, NJ
Impetus for this laborist program was high percentage of births to mothers on Medicaid
I have been working as a laborist for the past 8 years at Southeastern Regional Medical Center in Lumberton, North Carolina. The program began almost 20 years ago, when hospital administrators grew concerned about limited access to obstetrical care for Medicaid recipients, who accounted for more than 50% of hospital deliveries. They hired an obstetrician to focus on delivering infants in-house, frequently for women who had had little or no prenatal care. Over the years, nurse-midwives were added to the mix, and the program began to establish relationships with pregnant women at health clinics in the area.
The program has won awards at the state and national levels for its effectiveness in reducing infant mortality and low birth weight. Today it employs two certified ObGyns (I am one of them) and three certified nurse-midwives. Almost 17,000 babies have been born since the program began.
Walter E. Neal Jr, MD
Call for information
We are trying to start a laborist program at a hospital here in Charleston, using private practice-based physicians to stay in-house. I am seeking advice from individuals and institutions working with the laborist model to help get our program off the ground. Among the information I am seeking is the rate of pay per shift (both day and night) or for 24 hours. I also would like to know how hospitals and doctors divide the charges for the work done, or whether the hospital controls this aspect of the model completely.
Please email me at firstname.lastname@example.org if you have information to share. We can then set up a time to talk by phone, if you prefer.
Stan Ottinger, MD
For more on the laborist model of care, see these recent articles
- “The unbearable unhappiness of the ObGyn: A crisis looms,” by Louis Weinstein, MD, in this issue
- “Laborists, nocturnalists, week-endists: Will the “ists” preserve the rewards of OB practice?” by Robert L. Barbieri, MD (September 2007). Available in our archive at www.obgmanagement.com.