Here are some tips for consultants in the OBGYN field.
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Hospitals and their doctors request consultants for a variety of reasons, but OBGYN hospitalist related consultations are usually more specific.
Most requests originate from a hospital that is experiencing a series of bad outcomes in labor and delivery, which has led to malpractice events, or because local ob gyn doctors are stressed out and are looking for relief.
Sometimes these obgyn doctors learn of OBGYN hospitalist solutions while they are attending continuing medical education conferences.
The main reason either hospitals, a hospitalist company, an OB hospitalist group, or local obgyn physicians start an OBGYN hospitalist program is because it makes it safer for women in labor.
However, it also has the benefit of improving the work life balance for the private OBGYN’s as well as family practitioners and midwives who do deliveries.
Imagine being on call but yet able to sign out your responsibilities for a few hours in order to attend your child’s birthday party. This is just one example where obgyn hospitalists come into the scene.
Patients benefit because there is an experienced board-certified OBGYN physically present in the hospital to respond to an emergency and be available while their private practitioner is on the way into the hospital.
Patients are seen more rapidly for evaluation and studies show that the hospital experiences a reduced cesarean section rate.
In many hospitals, the OBGYN hospitalist also sees gynecologic emergencies in the main ED with the same rapid evaluation.
So although the reasons can vary for a doctor or hospital to request a consultation with a hospitalist about designing or enhancing a hospitalist program, it usually boils down to better patient safety and overall improvements for physicians and nurses and midwives.
If you have any questions or need to request Dr Olson for a consultation please contact Rob.
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
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
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
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 [now American Congress] 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. ObGynHospitalist.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 posted JANUARY 18, 2013 on ehospitalistnews.com
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
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.