ObGyn Hospitalists 101 – What does a hospitalist do?

The term “hospitalist” is commonly thought of as an internist or pediatrician model. However, in 2003, Dr. Louis Weinstein, professor and former chair of obstetrics and gynecology at Thomas Jefferson University Hospital, Philadelphia, proposed the idea of hospital-based obstetricians primarily to improve patient safety.

While there are various evolving models for what type of care an ob.gyn. hospitalist provides, he or she is generally considered to be a board-certified ob.gyn. who is physically present in the hospital, primarily in labor and delivery, although some programs require coverage of gynecology in the emergency room.

The ob.gyn. hospitalist is there for safety: They cover triage, labor, delivery, and postpartum care for all unassigned patients, as well as for those patients signed out to them by a private practitioner. They commonly assist at cesarean sections, respond to almost all true emergencies, and do consults and operative deliveries for family practitioners and midwives. Frequently, they are asked to stand by for deliveries while the private practitioner makes their way in from home or the office. On request, they also perform procedures such as artificial rupture of members (AROM), bedside ultrasound for position, and insertion of pressure transducer catheters.

While it may be obvious, there is evidence-based data which proves that hospitals with ob.gyn. hospitalists have an increased level of safety, which directly leads to a decrease in bad outcomes and subsequent medical malpractice costs. An excellent example is that an ob.gyn. hospitalist can begin a cesarean section for a prolapsed cord before a private practitioner can be there. When they do arrive, the private practitioner can take over the surgery, and the hospitalist can assist as required or requested.

In addition to clinical work, hospitalists teach, run simulations, and are leaders in implementing systemwide changes that increase patient safety, quality, outcomes, satisfaction, teamwork, and overall departmental improvements. They reduce the problems of fragmented care, may work as perinatology extenders, and are immediately available for any situation that arises.

There also are other unintended benefits of ob.gyn. hospitalists. Clinical decision waiting time is reduced, communication is increased, nurses can obtain immediate evaluations and recommendations, and hospital administrators can use them as a tool for marketing to patients as well as recruiting and retaining physicians and nurses.

Ob.gyn. hospitalists also facilitate an improved personal-professional lifestyle balance for general ob.gyns. and family physicians. Ob.gyn. hospitalists allow them to stay in the office or surgery when needed or sign out patients when fatigued or when they simply wish to take a vacation.

I have been an ob.gyn. hospitalist since leaving my solo general ob.gyn. practice in 2007. At that time, I could only identify 10-12 programs within an emerging ob.gyn. hospitalist subspecialty. Now there are over 150 programs across the United States, with one to two new programs emerging each month. My website, ObGynHospitalist.com, was established to provide a professional resource for ob.gyn. hospitalists, where over 800 registered members can access new opportunities, and a forum to exchange ideas and discuss all aspects of our fledgling subspecialty.

In September 2011, the nonprofit Society of Ob/Gyn Hospitalists (SOGH) was established. It now has over 60 paid members, and I am honored to be its founding president.

What Does a Typical ObGyn Hospitalist Look Like?

One of the reasons I started up my website, ObGynHospitalist.com, was to connect with other ob.gyn. hospitalists that I knew were out there. I wanted to know if they were experiencing the same challenges I was, what their program model looked like, if they were part time or full time, and what their pay and benefits were.
As the website membership grew, it was a logical step to ask members these questions directly.

The first Salary and Employment Survey was sent out in 2011 and had 106 respondents. This year, our third survey had 313 respondents and allowed us to clearly see consistent trends, particularly in ob.gyn. hospitalists’ experience levels, the types of shifts we work, and overall pay and benefits for both part time and full timers.

So, what does a typical ob.gyn. hospitalist look like? Our survey tells us that they are mostly male, between 40 and 59 years old, and are at least 6 years post residency.

Most ob.gyn. hospitalists work in hospitals that average more than 1,000 births per year, with most (45%) working in hospitals with 2,001-3,000 deliveries per year and 19% who work in hospitals with more than 4,000 births per year.
Most describe their primary practice activity as obstetrics with emergency department coverage including emergency gynecologic surgery and inpatient gynecologic consultations. They work full time and have had no change in their employment status over the last 12 months.

The most common full-time work schedule is exclusively 24-hour shifts. Those full-time hospitalists who don’t work 24-hour shifts mostly work 12-hour shifts and are happy with this arrangement.

Ob.gyn. hospitalists are “very satisfied” with their career, variety of work, management, recognition, and professional relationships.

Most work with other ob.gyns. and maternal-fetal medicine physicians only rather than with family practitioners or midwives. Half work as perinatology extenders doing some or most of their deliveries and half use perinatologists only as a consultant, like a private practitioner would.

The majority have ob.gyn. physicians sign out to them, and a third supervise midwives.

Most full-time and part-time hospitalists are hospital employees and are almost evenly split between receiving an hourly gross wage and a salary.

The most common full-time hourly rate (41% in 2012 and 34% in 2013) is $101-$110/hour; 4.5% earn more than $140/hour. Most part-time hospitalists earn less per hour than do full-time hospitalists, with an hourly rate of $91-$100/hour.

The most common full-time salary range (31%) is between $224,000 and $249,000; 4.7% earned between $325,000 and $349,999. The most common part-time salary range is less than $150,000. About 40% of full-time salaried physicians receive incentive compensation based on quality, not production.

A third of respondents stated that they need more physicians in their hospitalist program and that they do not have an adequate emergency backup call system in place. This is an important area for safety, and all programs should address the solution of emergency backup for the hospitalist.

It’s exciting to have this information, not only to know what experience our fellow ob.gyn. hospitalists around the country have, but also it’s interesting to know how other programs are structured, what responsibilities are commonplace, and how our salary and benefits compare with our general ob.gyn. colleagues. The 2013 report can be viewed at ObGynHospitalist.com/news, where you can also find previous survey reports, too.

How are ObGyn Hospitalists Different from General ObGyns?

The only difference between ob.gyn. hospitalists and general ob.gyns. is work location, right? We all undergo the same residency training, pass the same boards to become board certified, and you have to be a general ob.gyn. to become a hospitalist after all. So, in one sense, there are no differences.

In addition to clinical skills, however, hospitalists do differ. As I outlined in my column “Ob.Gyn. Hospitalist Character Traits,” a hospitalist must be a seasoned professional and a team player, be willing to serve, inspire trust, be a good communicator, and be trained and incentivized to implement system-wide improvements.

Along with character traits, it is generally acknowledged that ob.gyn. hospitalists possess a specific set of core competencies. I began trying to formally define these during my first American College of Obstetricians and Gynecologists annual clinical meeting (ACM) clinical seminar in 2010.

Dr. Bob Fagnant expanded on the initial ideas in a presentation at the second Ob.Gyn. Hospitalists’ special interest group meeting at the 2011 ACOG ACM in Washington, D.C. His presentation was well received, drew much interest from a large audience, and has initiated discussion that continues. The Society of Ob.Gyn. Hospitalists (SOGH) also has dedicated itself to defining the core competencies, but as this is such a new model of ob.gyn. practice, there is much yet to be debated, and discussion should be expected and encouraged.

As stated above, the ideal hospitalist should be a seasoned professional. ObGynHospitalistConsulting.com employment surveys from the past 2 years showed that only 7% of ob.gyn. hospitalists started hospitalist work within 5 years of completing their residency. I think all of us agree that it is very difficult for a new residency graduate to acquire the skills and experience to step in and perform as a hospitalist. Not to say that it’s impossible, just very difficult in light of most residency volumes combined with residency hour restrictions.

One idea that I have heard several academic centers beginning to discuss is that of a fellowship for ob.gyn. hospitalists. Advanced training in a fellowship could provide more experience for new graduates, but it would be especially helpful for experienced, board-certified ob.gyn. hospitalists to hone not only their clinical skills, but also learn the administrative, simulation teaching, team leadership, and information management skills to take existing hospitalist programs from good to great and to start new programs at the highest skill level.

This idea is in its infancy and faces obstacles. Most experienced ob.gyns. may be unwilling to leave their current private practice positions and return to the lifestyle, hours, and, especially, the payoff of a fellow. However, there may be creative solutions similar to executive MBA programs, such as online learning, reviewing curricula designed by the academic center, and periodically traveling to the center for weekends or more prolonged times for the hands-on clinical training and experience portion over a year or two. Introduction of a new additional program needs to be handled carefully because such a program for hospitalists cannot reduce or take away from the clinical training experience of current residents and maternal-fetal medicine fellows.

Like the development of the core competencies necessary for ob.gyn. hospitalists, it will be fascinating to watch the development of academic programs for ob.gyn. hospitalist fellows. It will be exciting to see the first graduates and even more exciting to see the first board-certified ob.gyn. hospitalist in a new subspecialty. Will an old hospitalist like me get grandfathered in if I can pass the new (yet to be determined) American Board of Obstetricians and Gynecologists’ board certification for ob.gyn. hospitalists?

We are lucky to have the SOGH in a position to hear discussion and debate and to advocate for commonly agreed-upon positions. There are so many questions to answer to define the difference between general ob.gyns. and hospitalist ob.gyns., but we are on the cusp of not an evolution in care for women in the hospital, but a revolution. The future is unknown, but the direction from the known is extremely positive. Not only is patient care becoming safer, but the system is becoming safer and more cost efficient while at the same time improving the lifestyle of the general ob.gyn. practitioner. This last sentence will be backed up by data and experience in the near future, I predict.

Originally published JANUARY 18, 2013 for clinicalpsychiatrynews.com

Character Traits of an ObGyn Hospitalist

Through my experience as an ob.gyn. hospitalist, it quickly became clear which things work well and which things do not in an ob.gyn. hospitalist program.

Although internal medicine and pediatrics have been using the hospitalist model for quite some time, it is still a model in its infancy for ob.gyn. medicine. With hospitals investing significant amounts of funding to start ob.gyn. hospitalist programs, there is neither time nor money to waste on pursuing the things that don’t work. The expectation is that even though it’s a new program, it should work almost immediately.

Those who have been through the torturous process of establishing, integrating, and/or converting to any new program in any aspect of life know that this is a fairly unrealistic expectation. There are, however, some basic ingredients or attributes that I believe must be present to lessen the pain and increase an ob.gyn. hospitalist program’s chances of success.

The following are some qualities that should be considered when ob.gyn. hospitalist candidates are interviewed:

• A physician who is a seasoned professional. Finding and then hiring the right people are always challenges in any industry, but even more so for ob.gyn. hospitalist recruitment. The best candidates for ob.gyn. hospitalist jobs need to be seasoned board-certified physicians. Not only will they be involved in every true ob.gyn. emergency, but they must also be able to educate and hold their ground against other, sometimes older ob.gyns., family physicians, and midwives who may not be practicing the most up-to-date, evidence-based medicine. This is not a job for a beginner. Physicians with expert clinical skills are essential for a program’s success, as they are the first responders and must be able to deal with or assist in every situation that presents itself.

• A physician who is a team player. The team needs to be flexible and responsible. Smooth handoff rounds, conveying all necessary information, are essential. An outgoing physician needs to introduce the incoming physician to any active patients. Scheduling needs to be fair and allow call dates to be traded to fit everyone’s schedule. Obviously, team members won’t know if they will be compatible until they start working together, but hospitalists must be willing to leave their egos at the door to be “team players.”

• A doctor who is willing to serve. The private practitioner obstetrician needs to keep her own patient happy and safe, whereas ob.gyn. hospitalists need to keep all the patients and all the labor and delivery professionals (and sometimes the gynecology emergency department professionals) safe and happy. Ob.gyn. hospitalists need to go out of their way to ask nurses and physicians the question: Is there anything I can do to help?

One of the great things about being a hospitalist is that the work is so varied, but programs need hospitalists who are willing to help anyone who asks and are comfortable doing so – from the private practitioner who needs a quick ultrasound to determine position, to the OR tech who requires help moving a patient. Some physicians may think these tasks are just scut work, but they are essential to developing a safe, efficient high-reliability organization (HRO) that can avoid catastrophe in a real crisis or emergency.

• A physician who inspires trust. Hospitalists are consistently meeting patients for the first time. They won’t have developed a relationship with patients over the previous months of pregnancy, so ob.gyn. hospitalists need to be able to bond with them and their families quickly. For example, one of the tools I find to be effective when I deal with a mom who has experienced a failed home birth by a lay midwife is this simple phrase: “I know this is not what you planned, but I am so glad that you are here with us so we can take care of you.”

• A doctor who is a good communicator. Hospitalists need to be able to solve problems quickly by using tact, diplomacy, and professionalism at all times. Being involved with emergencies and bad outcomes, they need to be comfortable with debriefing the team and communicating sensitively with patients and families. Highly developed communication skills also extend to documenting the chart and liaising with an absent private practitioner, the nursing team, and the hospital’s administration.

I was one of the original ob.gyn. hospitalists at my community hospital in Bellingham, Wash. Having Dr. Chris Swain’s company, the OB Hospitalist Group, consult helped us to quickly establish a successful new program. Our team of four hospitalists is employed by St. Joseph’s Medical Center. It is a successful program that I’m proud to say encompasses these aforementioned ingredients: We smoothly integrate our scheduling and handoffs; the local obstetricians, family practitioners, and midwives trust us and appreciate our work; and we regularly foster open communication by attending the nurses’ handoff meetings as well as huddling with the anesthesiologist and nurse team leader.

Originally published SEPTEMBER 25, 2012 for ehospitalistnews.com

 

Leadership Role in Quality and Cost Control – Hospitalist Programs

When an ob.gyn. hospitalist program starts at a hospital, there is often a varying degree of distrust, resistance, and uncertainty about how hospitalists fit into the rhythm of the labor and delivery department.

In the initial stages, the ob.gyn. hospitalist may be relegated to the sidelines and just used in a limited capacity – for an emergency or for patients without a physician, for example.

In established programs, it can be the other end of the spectrum, as ob.gyn. hospitalists are looked to for oversight, leadership, and standardization, and provide these skills, often facilitating how the L&D department operates overall. They can evolve into the manager of labor and delivery rather than only providing coverage.

I was recently intrigued by an article in the New Yorker entitled, Big Med by Dr. Atul Gawande, a surgeon, writer, and public health researcher, in which he compares the operation of his local Cheesecake Factory restaurant to hospital medicine. He observes how, unlike in medicine, the Cheesecake Factory has figured out how to “deliver a range of services to millions of people at a reasonable cost and with a consistent level of quality.” Lamenting the current state of hospital care, Dr. Gawande rightly states: “Our costs are soaring, the service is typically mediocre, and the quality is unreliable.”

Dr. Gawande also points out that doctors are paid for services, not results. Unlike a restaurant, historically medicine is not service oriented. Medicine is becoming like a chain restaurant as large corporations transform it into a Southwest Airlines approach to health care – a high-quality, low-cost product.

We need to keep working toward what the Institute for Healthcare Improvement calls the Triple Aim which seeks to improve the patient experience of care (including quality and satisfaction); improve the health of populations; and reduce the per capita cost of health care.

We need to demonstrate our value by continuing to emphasize our commitment to safety and quality outcomes.

It is necessary to demonstrate that our commitment to safety and quality outcomes translates into real improvement as well as real patient satisfaction. This is going to require data collection as well as new skills and competencies on our part. Not only will we have to hone our clinical skills, but we will also have to step up as leaders to work with the other members of the health care team.

How do quality and cost control occur? Is it even possible to deliver high-quality yet low-cost hospital medicine? And who is actually in charge to help make this happen?

Change in the medical world does not happen quickly; however, the adoption of ob.gyn. hospitalists is one way hospitals can immediately start addressing these issues.

Ob.gyn. hospitalists can be used in a leadership role with responsibility for a patient’s overall care, medical costs, and results. The can coordinate who cares for the patient and how, help reduce costs in malpractice by being physically present in L&D to handle emergencies or other challenging situations, oversee collaboration on standardization to deliver consistency and best practice medicine, and ensure good patient outcomes through their presence, clinical skills, and experience.

The military uses the term C4 – command, control, coordination, and communication. Adapting this for the medical environment could look something like this:

 Oversight instead of command. This can be done by facilitating how the department runs, prioritizing and assigning assets, and being the diplomat and intermediary between hospital administration and L&D.

 Leadership instead of control. This is accomplished by instituting standardization, ensuring best practices, and facilitating policy integration to enable collaboration and consensus to achieve the best possible outcomes at the lowest cost.

 Coordination. The ob.gyn. hospitalist can coordinate between patients and their family physician, midwife, or obstetrician; coordinate between the private practitioner and the ob.gyn. hospitalist; and coordinate between nurses and physicians in L&D, and the patient during follow-up.

 Communication. The ob.gyn. hospitalist can work to ensure that everyone from the L&D floor to the hospital administrators knows what is going on all of the time.

It is fascinating to watch this process occur in real time and to be part of this transformation. There are so many different variations of how ob.gyn. hospitalists are used in different programs. However, I think this gradual shift from coverage only toward oversight, leadership, coordination, and communication is inevitable. Because this transformation makes common sense and because it leads to greater patient safety with better outcomes at the same time, it reduces stress and improves working lifestyles for the private ob.gyn. as well as family physicians, midwives, and the labor and delivery nurses.

Originally published OCTOBER 24, 2012 on ehospitalistnews.com and edermatologynews.com