Some Health Systems Explore Laborists Idea
Nov.–Dec. 2005
Practice takes pressure off doctors and helps lower costs of malpractice insurance.
When Legacy Health System of Portland, Ore., announced that it would open a second hospital 15 miles away in Vancouver, Wash., it met with some unexpected grumbling — from obstetricians.
Schedules worked out among groups of community obstetricians allowed most doctors to have a few nights off between being “on call” to deliver babies. A second hospital would double coverage needs and could result in doctors having patients in both simultaneously.
“I was greeted with hostility,” says a wry Duncan Neilson, chief of women’s services at Legacy.
But then Neilson thought, why not hire doctors who will work only in the hospital, mainly delivering babies?
By hiring what have been called “laborists” and paying their malpractice insurance costs, the hospital could take the pressure off community doctors and possibly help with two related problems. Nationwide, fewer doctors, including obstetricians, want to serve “on call” for hospital emergency rooms. And rising malpractice insurance costs are causing some obstetricians to retire or cut back on OB services.
The handful of hospitals that currently have laborists say the doctors mainly care for uninsured women who come in through the emergency room or whose personal doctors can’t make it to the hospital in time.
But one proponent, Louis Weinstein of Thomas Jefferson Medical College in Philadelphia, says laborists may eventually become commonplace, with women having one doctor for prenatal care and a different one to deliver her baby.
In the traditional practice of obstetrics, obstetrician/gynecologists juggle a variety of roles — delivering babies, performing hysterectomies, doing office visits and providing prenatal care — efforts that sometimes keep doctors busy around-the-clock.
“It just doesn’t work anymore,” says Weinstein, chairman of the department of OB/GYN at Jefferson. “Young people don’t like to work these hours, and it’s not good for patient safety.”
He estimates there are about 10 hospitals nationwide using laborists, whom he says can save hospitals money by helping them avoid malpractice lawsuits. One of the biggest causes of malpractice cases in obstetrics, he says, is when labor goes awry and an OB isn’t immediately available.
The idea for laborists grew out of another movement, which began in the late 1990s when a new type of doctor emerged in the nation’s hospitals, called “hospitalists.” Such doctors care for patients throughout their hospital stay, a job formerly done by the patients’ own private-practice doctors. From a few hundred in the late 1990s, there are now about 15,000 hospitalists, says Larry Wellikson, a doctor and CEO of the Society of Hospital Medicine.
Still, Wellikson says, there are only a few laborists, and some patients may “be a little frightened to have a delivery by a stranger.”
Doctors, too, may not want to give up what, for many, is the best part of their jobs: delivering babies. “There’s a lot of emotion about this,” Weinstein says. “Most of the negative emotion is from people over 50, and the positive stuff is from younger people, which is exactly what I expected.”
Weinstein says patients today are used to seeing different doctors. Except for a few solo practitioners, most obstetrics practices tell patients that they may be delivered by one of the practice’s partners if their own physician is on vacation or otherwise unavailable.
Delphi Healthcare Partners, a contract management and physician recruiting agency, says the laborist idea is catching on. Delphi provides laborists to two California hospitals and is recruiting obstetricians for a new program at a Manassas, Va., hospital.
David Joyce, CEO of Delphi, says such programs, which pay doctors $180,000 to $220,000 a year, can save hospitals money because having a doctor available at all times to tend to emergencies during deliveries will help hospitals avoid malpractice lawsuits. Teaching hospitals generally have obstetricians available on-site around the clock, but community hospitals may not.
“In labor and delivery, things can go really bad very quickly, sometimes in a case of seconds,” Joyce says.
Washington Hospital Healthcare System in Fremont, Calif., has four doctors whose main duty is to deliver babies of uninsured women who come in through the emergency room and provide backup for insured patients whose doctors may not be available.
“The ER doctors love us being there,” says Ed Cohen, an OB hospitalist at Washington Hospital in Fremont. “It used to be difficult to get someone with an office full of patients to come over unless it was truly an emergency, whereas I’m in the hospital and can be there in two minutes.”
Cohen, who started his job seven months ago after 26 years in private practice, works seven to eight 24-hour shifts a month.
A similar program is planned for Legacy, where laborists will deliver all the babies from high-risk mothers seen by a local group of perinatologists, as well as women who come in through the ER. They’ll also provide backup for community physicians who can’t get to the hospital, such as if they are delivering a baby at Legacy’s Portland facility.
Neilson says he was overwhelmed by the response to his want ad seeking experienced, midcareer obstetricians who want to be laborists. “Very rapidly, I got 60 responses from all over the country from doctors really, really interested in this concept.”
For doctors applying for the job, the draws are having a position with a set schedule, no office overhead and malpractice insurance provided by the hospital, he says. Community doctors, while still required to serve on-call in the emergency room, are expected to be called in far less frequently.
Weinstein, who first wrote about laborists in an article in the American Journal of Obstetrics & Gynecology in 2003, this spring gave a talk on the subject at the annual meeting of OB/GYN doctors in San Francisco.
He’s heard from a number of doctors since, some supporting the idea and others fearing it will become commonplace, cutting into their incomes. Delivery fees are often a substantial portion of what a doctor is paid for medical care throughout a woman’s pregnancy.
Weinstein says doctors would make up that loss through savings on malpractice insurance. For hospitals, he says, avoiding just one lawsuit in five years would pay for the programs. But, he admits, he has stirred up some controversy because the idea of laborists is so different from traditional practice.
Source: By Julie Appleby, USA TODAY, a division of Gannett Co., Inc. Reprinted with Permission.
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