Here are some tips for consultants in the OBGYN field.
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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:
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:
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.
1 The first tip is if you do not ask, then you will not get. Too many physicians accept the “standard” contract, sign it without a careful review, do not ask nor negotiate more favorable terms, and do not pay the $500-$1000 to have an attorney review it.
2 It is harder to get major changes in subsequent contracts then it is in the first one. But even in subsequent contracts, it is easy to ask for things like pay raises, more paid time off, more paid CME, and if on salary-to ask for fewer shifts per year. You will be surprised to find that the human resource people, or whoever reviews your contract, frequently will grant you these increases, BUT ONLY IF YOU ASK!
3 If your hospitalist group all have their contracts renew at once, it is worthwhile getting together to try and negotiate a better deal for all of you. You can share the cost of the attorney to review for you (and possibly negotiate for the group).
4 Compensation: Read the salary survey results in www.societyofobgynhospitalists.org . Have a good idea what other OB/GYN hospitalists are being paid in the geographical area. Just call them up and ask. Most colleagues will give you a general idea. After all, you would do the same for a newcomer, correct?
Most OB/GYN hospitalists get either hourly pay or salary for so many shifts per year with only the exceptional position also having productivity factored in. Beware “bonus” additions to salary—be sure they are easily obtainable (ask currently employed hospitalists if they have received their “bonuses”).
5 Watch out for restrictive covenants—how long and how large a geographical area (footprint)? Are they restricted to OB/GYN hospitalists versus general OB/GYN in private practice? Will you have to leave the area if this hospitalist job does not work out for you?
6 Malpractice insurance: Do not sign unless employer provides occurrence malpractice insurance or claims made with employer paying “tail coverage.” If you are working part-time and pay for your own malpractice insurance, ask for an increased hourly wage because the hospital (or employer) does not have that expense in your particular case.
7 Especially with your first contract, engage an attorney who concentrates his or her practice on physician employment agreements. Let them negotiate the deal for you without you alienating your future employers. You can let the attorney be the “bad guy.” You can just say, “I don’t understand this legal stuff,” or “My attorney is making me ask for…”
8 Ask for a sign-on bonus and/or ask for moving expenses (why not? They can just say no).
9 Negotiable costs: Employer paid CME, medical staff dues, DEA fees, transportation costs, and medical Society dues are all negotiable, while disability, health insurance, and retirement packages are generally less negotiable.
10 Other negotiable expenses: Payment of previous malpractice tail insurance, debt, and/or loans can sometimes be negotiated over years of service (generally at least three years).
11 Not-for-cause termination: 90 days is common; try for 120 days—the duration should be the same for both you and the hospital (employer).
12 If you are working for a staffing company, will there be “ownership” opportunities in the future-stock options, etc.?
As an independent contractor, I have been negotiating my own contracts for over eight years (using my accountant as an advisor) I have taken some of these ideas from a recent book I reviewed: The Final Hurdle: a Physician’s Guide to Negotiating the Fair Employment Agreement by Dennis Hursh, published 2012.
Information for Hospitalists on Legal Issues, Contracts, and Negotiation:
A sample hospitalist contract:
I, of course, am not an attorney and I am not offering legal advice here or anywhere, but I have spoken to a lot of different OB/GYN hospitalists about their contracts and would be glad to share my experience if you would like to contact me.
Good luck in negotiating your own contracts!
Rob Olson, MD, FACOG
Did you know that the Society of OB/GYN Hospitalists is holding its second annual clinical meeting on Sept. 27-29, 2012, in Denver? Did you know that the Society of OB/GYN Hospitalists (SOGH) even existed? With more than 100 paid founding members, SOGH is not yet widely known within the ob.gyn. community; however, it did not emerge overnight.
Formally established in 2011, it came about due to a group of like-minded and dedicated ob.gyn. hospitalist volunteers who, like me, wanted to create a formal community that would address our specific needs, answer our particular questions, and reinforce, bolster and support our emerging position of influence in ob.gyn. hospital care.
With the concept of the “ob.gyn. hospitalist” widely embraced only since 2003, I wasn’t sure how many other physicians were practicing this model of ob.gyn. care. I was certain I wasn’t alone, so in 2008 I launched my website ObGynHospitalist.com [now obgynhospitalistconsulting.com] to make sure. It was a fairly “homemade” effort at first, but approximately 175 ob.gyn. hospitalists of varying descriptions joined my site in its first 2 years. I had gathered together a community of disconnected, somewhat frustrated, and often isolated hospitalists who were motivated to connect and exchange answers with one another.
As the number of members grew, and the website became the only professional resource for ob.gyn. hospitalists, there was increasing interest in getting together in person. In 2010, I requested that the American College of Obstetricians and Gynecologists (ACOG) allow us to hold a Special Interest Group meeting at its annual clinical meeting (ACM) in San Francisco. I was thrilled that more than 75 people showed up and a lively discussion of hospitalist-specific issues clearly showed that there was a need for a more formal organization to be formed.
An organizational meeting was held in Denver in October 2010 with 17 people in attendance. A pivotal moment at that meeting was when Dr. Larry Wellikson, the Society of Hospital Medicine’s CEO, gave us invaluable advice on how to form a nonprofit medical society.
A second Special Interest Group meeting was held at the 2011 ACOG ACM in Washington, D.C. This provided the impetus and the volunteers to start organizing the society’s first ACM. In September 2011, it all came together. With 43 enthusiastic ob.gyn. hospitalists, generalists, and administrators in attendance, SOGH was officially born.
Cochaired by Dr. Karenmarie Meyer and myself, the conference covered a range of important clinical and business issues that affect ob.gyn. hospitalists. Presentations included best practices in obstetric triage and evidence-based cesarean section techniques. Data collection techniques, safety and malpractice issues, and ob.gyn. hospitalists’ core competencies also were discussed. The SOGH board of directors was elected. Volunteers signed up for four separate committees, and committee chairs were elected.
Following the ACM, The Doctors Company conducted a first-of-its-kind Obstetrical Emergency Simulation Workshop. One of the highlights was the attendance of Prof. Christopher B. Lynch, who flew in from the United Kingdom to personally demonstrate his B-Lynch suture. He will again be in attendance for the simulation workshop on Sept. 27, 2012.
Last month SOGH achieved another milestone with the launch of its website SocietyofOBGYNHospitalists.com, which is where you can find this year’s ACM schedule and registration form, as well as SOGH membership applications.
As SOGH’s outgoing founding president, I’m proud to have overseen its inception, birth, recognition as a nonprofit 503(c)3* organization, and the preparation for the second ACM. Dr. Meyer takes over as president after the ACM, and I look forward to watching it mature in the years to come.
Originally posted AUGUST 17, 2012 on ehospitalistnews.com
This month I’d like to introduce you to two leaders in the ob.gyn. hospitalist field.
The first is Dr. Wayne Farley of Questcare Obstetrics, based in Dallas. It currently has ob.gyn. hospitalist programs in Texas, but has recently expanded to Colorado.
Questcare’s first program was established 5 years ago, and in 2008, Dr. Farley stated: “I’m sure the face of our ob.gyn. hospitalist programs will look much different in 2012-2013.” That vision has proven to be very true, and he still believes that Questcare’s programs will continue to evolve with time.
Dr. Wayne Farley
Dr. Farley attributes the program success of Questcare to its focus on the development of perinatal service lines that the facility could not otherwise support. In fact, they have successfully created a variety of these programs for the facilities with which they are currently contracted and hope to expand them in their future contracts.
Questcare Obstetrics is currently expanding perinatal service lines to include high-risk obstetric referral centers. Even more specialized is the Advanced Maternal & Newborn Institute and Specialty Obstetrics Referral Center at Medical City Women’s/Medical City Children’s Hospital in Dallas. This program offers patient-focused outpatient and inpatient care of pregnancies complicated by fetal anomalies and/or chromosomal aberrations.
In addition to high-risk referral centers and specialty clinics, Questcare also has facilitated the development and implementation of a successful maternal transport program.
With this evolutionary change in Questcare’s ob.gyn. hospitalist programs in just 5 years, it should be interesting to see what the next 5 years bring. Questcare Obstetrics is focusing on providing quality ob.gyn. hospitalist programs, while helping expand targeted service lines for its contracted hospitals.
The development of these programs may seem out of the realm of what ob.gyn. hospitalist programs normally bring to a facility, but Questcare’s programs have brought a significant value-added contribution to the hospital without adding to the overall costs of healthcare.
The second person I’d like to introduce is the current president of the Society of OB/GYN Hospitalists (SOGH):
Dr. Karenmarie K. Meyer
Dr. Meyer is a great advocate of the ob.gyn. hospitalist model, and her goals for the fledgling society include defining what an ob.gyn. hospitalist actually is, delineating the criteria for hospitalist core competency; championing patient safety for women in the hospital, emergency department, and in the labor and delivery setting specifically; adding simulation training as part of our core skill set; and documenting our results through research and publications. Dr. Meyer has led significant progress in all of these areas and SOGH has been recognized as an organization whose members will take the lead in determining how ob.gyn. hospital care is provided in the future.
Passionate about the broadening understanding of the model, Dr Meyer recently stated: “Ob.gyn. hospitalists are much more than just an ‘in-house’ doctor available for emergencies. As our membership and visibility continue to increase, others are realizing this as well. Our members are up to date on current management protocols, and our availability to private physicians and their patients has been well recognized in hospitals utilizing our practice model. Our knowledge, consistency, and reliability will continue to define us as the ‘state of the art.’ ”
Dr. Meyer and SOGH are continuing to identify hospitalists’ core competency criteria and how these will be assessed and certified. SOGH also has been asked to help define the core criteria for the first fellowship in an ob.gyn. hospitalist discipline, which is being offered by Dr. Anthony Vintzileos at Stony Brook in N.Y.; the fellowship will be established at Winthrop University Hospital, Mineola, N.Y. The second program will be at the Fountain Valley Regional Hospital associated with the University of California, Irvine.
As the ob.gyn. hospitalist model matures and changes, Dr. Farley’s and Dr. Meyer’s contributions are exciting and are helping to define and drive the future of women’s inpatient care across the country today.
Originally posted MAY 21, 2013 on ehospitalistnews.com
Up to now, I have been commenting mainly on ob.gyn. hospitalists’ impact on labor and delivery, but our surveys show that the majority (64%) of ob.gyn. hospitalists also have responsibility for seeing gynecologic patients in the main emergency department as well as inpatient consultation.
Most gynecologic emergencies are as you would suspect: threatened miscarriage, ectopic pregnancy, pelvic inflammatory disease, and, to a lesser extent, torsion of benign tumors as well as the occasional malignancy, and the common vague abdominal pain syndromes. Ob.gyn. hospitalists provide the main emergency department with the type of service that they provide in labor and delivery (L&D) triage or the obstetric ED: immediate or at least rapid response, expert clinical care, and the ability to work with the team in the ED or with other team members such as surgeons in the case of major trauma involving either pregnancy or gynecologic organs. This rapid response results in increased patient satisfaction as well as a more efficient ED.
However, having an ob.gyn. hospitalist cover the ED comes at a cost, as it physically takes him or her away from covering potential emergencies in the L&D area. Some hospitals get around this problem by allowing the ob.gyn. hospitalist to only go to the ED when they’re unoccupied; or if they make a diagnosis requiring surgery, they will call the on-call gynecologic surgeon so that the ob.gyn. hospitalist is not in the operating room with a case just when they’re needed for a shoulder dystocia or prolapsed cord in L&D.
This compromise of allowing diagnosis but not surgical treatment is a good one because even though the main ED is frequently geographically separate from L&D, the ob.gyn. hospitalists can usually rapidly leave the main ED to respond, while they could not provide the same response if they were in the middle of a surgical case. Having a backup gynecologic surgeon on call also provides a mechanism for outpatient follow-up for a medically treated gynecologic emergency patient.
Well-run programs also have an obstetric physician on backup call for follow-up of unassigned outpatient obstetric patients who need to be seen after triage or obstetric ED visits. More importantly, these programs have a backup physician if the ob.gyn. hospitalist gets either too busy or too fatigued. However, our most recent ob.gyn. hospitalist.com employment survey shows that between 35% and 45% of programs do not have an adequate emergency backup system in place to cover the hospitalists (www.obgynhospitalist.com) [now obgynhospitalistconsulting.com].
Rapid and easily obtained gynecologic consultation also helps with improved patient care, diagnosis, treatment, and turnover of inpatient beds. With in-house ob.gyn. hospitalists, the days of internists, family practitioners, and traditional hospitalists having to wait until after office hours for a gynecologist to see an inpatient are over. Traditionally, that consultation would take place at 6 p.m. or 7 p.m., and then additional ordered diagnostic imaging might not take place until the next day, adding unnecessary delays in diagnosis and causing longer hospital stays than necessary.
Gynecologic responsibilities add to the body of knowledge that ob.gyn. hospitalists need to be skilled at, especially with diagnosis and medical treatment. However, requiring hospitalists to provide gynecologic coverage also emphasizes the potential challenge of how to maintain superb gynecologic surgical technique. This is difficult with low volumes of surgical cases. Once again, this problem can be eliminated if there’s a gynecologic surgeon to do the work in the operating room. This is also an area that is of particular interest to the Society of OB/GYN Hospitalists as they discuss and decide which skills and competencies hospitalists must possess and maintain.
Originally posted FEBRUARY 14, 2013 on ehospitalistnews.com