obgyn hospitalists

The ABCs of OBGYN Hospitalists

OBGYN hospitalists are generally board-certified obstetrician-gynecologists who focus their practice on hospitalized women and generally do not have an outpatient office. Hospitals hire them for several reasons but the most important is for safety. Especially in obstetrics, the clinical situation can change so rapidly that unless a physician is actually in labor and delivery to respond on an emergency basis there can be a bad outcome for mother or baby or both.

Just like the rapid penetration of internal medicine hospitalists, OBGYN hospitalist programs are spreading. Although a few programs have been around for many years, in 2007 there were only approximately 15 in the United States, and currently there are over 244 with two to six new programs starting up monthly. It certainly is not standard of care yet but I’m predicting it will become standard of care within three to five years. Some people use the word Laborist, but a better term is OBGYN hospitalist for those programs in which there is responsibility not only of labor and delivery, but also of gynecologic emergencies in the main ED (Emergency Department). OB hospitalists only stay in labor and delivery and the private OBGYNs staff the main ED.

Financially speaking, almost all programs lose money. Depending on the volume, that loss can be between $1-$200,000 or up to 1 million dollars. Roughly, a program costs $1.5 million and the income it generates can bring in $500-$750,000 a year. Hospitals with 2000 deliveries or more have a lower amount of loss. It is important to look at a wider budget rather than simply profit or loss because:

  1. Bad outcomes lead to malpractice costs
  2. Hospitalists can increase the volume of high-risk pregnancies that can help to fill up the neonatal ICU, which can be a profit center for hospital
  3. Retention and recruitment of not only physicians but of the expensive-to-train labor and delivery nurses

Many hospitals help pay for the program by transforming their outpatient OB triage areas into OB emergency department (OB ED). This increases the facility fee for evaluation substantially.

Many hospitals are facing the same problems:

  1. OBGYNs do not want to take call
  2. There are unassigned patients
  3. There may be midwives and family practitioners doing deliveries without backup
  4. No one wants to accept the transfer of high-risk patients
  5. Patients wait a long time for evaluation
  6. Maternal Fetal Medicine specialists want to do an outpatient practice only and not come to the hospital
  7. No one wants to do vaginal births after cesarean section (VBACs)
  8. The cesarean section rate is too high

An OBGYN hospitalist can help with all of these issues, making the private practitioners happy by taking the call, caring for the unassigned and high-risk patients, consulting for the family practitioners and midwives, evaluating patients promptly, working collaboratively with the MFM specialist, encouraging VBAC by taking responsibility while the private practitioners stay in their office, and studies prove that having professional full-time OBGYN hospitalists reduces the C-section rate.

There are no great downsides other than the direct costs to the hospital. Initially the private practitioners are skeptical, but within a few months they become the program’s biggest fans. Patients are satisfied and studies prove this. Nurses are supported and empowered. It can become a very important competitive advantage for a hospital that has a nearby competing hospital.

 

OB Hospitalists + MFMs = Better Outcomes

It is a sad fact that not only are there are more and more high-risk pregnancies, but there are not enough maternal-fetal medicine [MFM] physicians to help care for them.

Some fellowship programs are emphasizing outpatient consultation and ultrasound rather than the critical care of the high-risk inpatient. There are not enough perinatologists to treat the growing number of elderly mothers and diabetics or to handle the increase in obese, hypertensive, and multiple gestation pregnancies.

Additionally, just like everyone else, maternal-fetal medicine physicians (MFMs) have the pressure of being in two places at once: the office and the hospital. Small group or solo practices feel this strain even more, and many times limit their practice to outpatient consultation only.

As most of us in the hospital trenches know, this MFM shortage can create the perfect storm for a very bad outcome. However, ob.gyn. hospitalists can step into this void.

In January 2012, ObGynHospitalist.com conducted the first survey to find out how ob.gyn. hospitalists and MFMs are working together. It revealed that more than 70% of ob.gyn. hospitalists work with high-risk patients, and the vast majority work with private-practice or hospital-employed MFM specialists, most often on a daily basis.

Another significant finding from the survey was that the majority of ob.gyn. hospitalist programs do not or rarely share patients with the local MFM(s). In the one-third of programs that always or mostly share patients, the ob.gyn. hospitalist is the assigned admitting physician half the time, a MFM is the assigned admitting physician 14% of the time, and 38% stated that it could be either.

Most shared patients are seen by either an ob.gyn. hospitalist or MFM(s). Ob.gyn. hospitalists perform floor rounds on shared patients 23% of the time, round together with a MFM(s) 12% of the time, and MFMs exclusively make floor rounds on only 10% of shared patients. Separate rounds are performed 24% of the time.
This partnership that is created between the MFM and the ob.gyn. hospitalist means that hospitalists can be MFM extenders, and high-risk patients can be given more immediate attention.

I was recruited by Dr. Reinaldo Acosta, a solo MFM who could only do outpatient consults and couldn’t take call until he started an ob.gyn. hospitalist program in Spokane, Wash., in 2007. The results were tremendous. The hospitalist took care of his inpatients, he could take call because he rarely had to come in at night, and he was usually not disturbed in the office. He was covered for vacations and several weekends a month by a locum, Dr. Jorge Talosa. Over 4 years, neonatal intensive care unit bed occupation numbers increased from 8,302 to 15,625, and Dr. Acosta created new sources of revenue for the hospital by increasing transports of very sick mothers and preterm deliveries. It also allowed the hospital to have both better safety and quality of service, because a board-certified ob.gyn. was present 24/7 to handle emergencies and support the private ob.gyns. and family practitioners.

This new model, where general ob.gyns. act as perinatology extenders, benefits everyone. It also addresses the shortage of MFMs as well as the increasing number of high-risk patients. As ob.gyn. hospitalists develop their clinical obstetric skills and experience, they may complement MFMs as the primary caregiver to high-risk women in the hospital. It will be interesting to see how this develops. Will the 4-year general ob.gyn. residency change? Will there be a special fellowship in ob.gyn. hospital medicine? Will there be a separate board certification?

Ob.gyn. hospitalists want to – and should – have a closer working relationship with their local MFMs. This isn’t just to increase and find new revenue for hospitals; it can benefit all obstetric patients, ob.gyn. hospitalists, and MFMs, as well as community obstetricians and the hospital’s obstetric service, too. The ObGynHospitalist.com [now ObGynHospitalistConsulting.com] survey results lend legitimacy to the relationship, but it’s up to the stakeholders to forge closer ties and adopt this new partnership model to improve high-risk patient care.

Originally posted JULY 25, 2012 on ehospitalistnews.com

More Than Just a Job – My Job as an OBGYN Hospitalist

It’s bittersweet that this will be my last column, but I appreciate the opportunity that this news organization [ehospitalistnews.com] has given to me, and it’s been an honor to share my thoughts about the new ob.gyn. hospitalist model, how it is changing our profession, and the future that lies ahead.

This is an exciting time to be in this rapidly evolving field because this is a new way of delivering health care to women by utilizing board-certified ob.gyns. who are physically present in the hospital. Their presence has led to proven increases in patient safety, a demonstrable reduction in bad outcomes, as well as decreased malpractice costs.

Additionally, programs not only lead to increased lifestyle satisfaction for hospitalists, but contribute to reducing private ob.gyns.’ stress and conflict of needing to be in the office and the labor and delivery department.Although hospital administrators have to pay the considerable gap between the costs of these programs and the amount of billing provided to the hospital by the work the physician hospitalists perform, administrators also are very satisfied. This can be seen by the veritable explosion of new hospitalist programs across the United States. When I began my career as a hospitalist in 2007, I could only find 15 programs, and now there are 200 nationally.

If I speculate and try to imagine 3-5 years in the future, I think there will be ob.gyn. hospitalists in at least 75% of all hospitals delivering 2,000 or more babies per year. That means there will be at least 102 programs employing approximately 612 (6 × 102) hospitalists.

For those of you considering this opportunity, it is a chance to reduce your work hours by moving to hourly shifts instead of days in the office and nights on call. You can have a good salary while having a life outside of medicine as well. You can hone your clinical skills by concentrating on obstetrics and perhaps emergency gynecology cases as you learn to work in teams; implement systemwide improvement; and have a greater emphasis and potential impact on patient outcomes, satisfaction, and quality.

It is a profession and not just a job. It is one of which I’m proud and love to do. I am convinced that having ob.gyn. hospitalists makes it safer for women. It is an opportunity to get in at the ground floor and help influence our profession’s newest model of care that is changing women’s inpatient care in this country right now and for many years to come.

Originally posted JUNE 20, 2013 on ehospitalistnews.com