I Love My Job – Hospitalist Job

I love my job.

“Choose a job you love, and you will never have to work a day in your life.” – Confucius
Everyone knows this Confucius quote. Its overuse makes it sound cheesy, unrealistic, and it’s dubious that a Chinese philosopher who died in 479 BC could still be relevant in today’s fast-paced modern world. I am, however, now a believer because I love my job and it doesn’t feel like work. Honestly.

I enjoyed having a solo general ob.gyn. practice and reveled in its multidimensional challenges: running an office, being able to choose my own great staff, developing long-term rewarding relationships with my patients, and doing complex gynecologic surgeries. However, after 28 years, I heard Dr. Lou Weinstein give the first lecture I was aware of at the American College [now American Congress] of Obstetricians and Gynecologists Annual Clinical meeting in 2005 about ob.gyn. hospitalists. I returned home and put my practice up for sale.

I wanted to use my array of skills outside a traditional office setting and reduce my stress levels. To find that elusive work/life balance and influence best practices in obstetric medicine, I needed to find a job that I loved, not merely enjoyed.

Five years ago, I found a second career in which I could do all these things, truly specialize in obstetrics, and hone my clinical skills into a defined purpose: improving patient care and safety. I became an ob.gyn. hospitalist.
Prior to becoming an ob.gyn. hospitalist, my biggest frustration at my private practice was that I constantly had to be in two or three places at once. Balancing this physical impossibility among laboring patients, keeping office appointments, and being required in surgery was my greatest source of stress. Today, my attention is focused solely on labor and delivery (L&D). My hospital doesn’t require me cover to emergency department gynecology, which I believe is safer for the patients because, without additional gynecological responsibilities, I am not overextended and can focus all my energy exactly where it is needed. It is safer for women in labor to have me physically present in L&D rather than be in the ER, or worse, in the operating room.

Safety is what drives the whole ob.gyn. hospitalist movement. It is gratifying to see all of the reports of patients “saved” because of the presence of an ob.gyn. hospitalist. (Become a registered ObGynHospitalist.com member to see more than 40 examples of “saves and “near misses” in the Discussion forum under the Clinical Issues tab [or register at our new site here at ObGynHospitalistConsulting.com]). We are working on collecting data to prove this, and the Society of Ob/Gyn Hospitalists (SOGH) has a dedicated Research, Education, and Safety Committee to document what we already anecdotally know.

One of my first “saves” as an ob.gyn. hospitalist came about when a family practitioner was attempting to deliver a baby at 2 a.m. and encountered a severe shoulder dystocia he couldn’t resolve. By the time I arrived in the delivery room, it had already been between 2 and 3 minutes. I was fortunate to be able to step in and complete the delivery without harm to either the mother or infant. In contrast, if an on-call obstetrician had been summoned from home, there may have been a very different outcome.

The combination of experience, skills, and, most importantly, my presence in L&D created a positive outcome. This is another reason I love my job: I can truly make an immediate difference just by being there. And that’s not work.

Originally posted MAY 17, 2012 on ehospitalistnews.com

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

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