OB/GYN Hospitalists: One Hospitalist's Take
It was hoped and expected that OB/GYN Hospitalists would improve the quality and safety of obstetric care.
When I tell people that I am an OB Hospitalist, I am often met with a quizzical expression and asked, “What is that?”
According to the Society of OB/GYN Hospitalists (SOGH), “the OB/GYN Hospitalist is an experienced OB/GYN physician with a practice focused on managing the OB/GYN care of the hospitalized patient.” The American College of Obstetrics and Gynecology (ACOG), in their February 2016 Committee Opinion, defines the position more simply: “a physician whose primary professional focus is the general medical care of hospitalized patients.”
But it's not quite as simple as either of those definitions might imply. An OB Hospitalist does not perform a single uniform job. He or she may be asked to cover only labor and delivery, the emergency department, inpatient units, provide cross-coverage with midwives and residents, be used as maternal-fetal medicine specialist extenders — or any combination of the above. Training can also vary. He might be a general OB/GYN, or trained in hospitalist care through a fellowship or even a maternal-fetal medicine specialist. Similarly, there are many ways to be employed, including independently contracted, employed by a hospital or physician group or even through staffing companies.
The 2013 OB/GYN Hospitalist survey by SOGH reports that the “typical” OB/GYN Hospitalist is male and between 40 to 59 years old. He is most likely to work full-time and cover 24-hour shifts and, if he is employed full-time, earn $101-$111 per hour. Also, according to the survey, in an average month, an OB/GYN Hospitalist performs 5 to 6 vaginal deliveries, 3 to 4 cesarean deliveries, 1 to 2 vaginal births after cesarean deliveries (VBACs), 1 to 2 cesarean surgical assists and 1 to 2 other surgical procedures. There were no circumcisions, hysterectomies or GYN surgical assists reported in the survey. As it was a self-reported survey, recall bias cannot be ruled out.
It was not until 2002 that the hospitalist model was applied to OB/GYN. It was hoped and expected that OB/GYN Hospitalists would improve the quality and safety of obstetric care. It was also anticipated that the model would reduce the rate of cesarean section and provider fatigue and burnout, while improving the standardization of OB medical care and providing backup for other physicians. It was also thought that having OB/GYN Hospitalists on hand would reduce malpractice claims.
Some of these hopes have been realized, according to new studies — but not all. On the plus side, a study by Yee, et. al., concluded that the hospitalist work model makes it more likely to allow a trial of labor after cesarean (TOLAC) compared to more “traditional” call schedules. In this study, 22.6% of patients underwent TOLAC and 12.8% experienced VBAC. Of the patients attempting a TOLAC, 56.5% had a successful VBAC. Women who had a successful VBAC were more likely to have a provider who was working the "night float" as compared with one working the "traditional call" (33.1% vs. 16.5%, P<.001). Once a TOLAC was begun, the complications related to TOLAC were not statistically different between the 2 types of providers.
A study by Metz, et al., found the overall cesarean delivery rate to be 24.1% in a public hospital. There was a 3-fold variation in cesarean delivery rates between identified “laborists.” This variation was independent of patient characteristics. The downside to having a lower cesarean rate was that more cases had a fetal cord gas with a pH<7.0.
Finally, 1 study did not conclude that the hospitalist work model was superior. Srinivas, et al., found that hospitals with laborists were associated with fewer labor inductions (adjusted OR [aOR], 0.85; 95% CI, 0.71-0.99) and a decreased rate of preterm birth (aOR, 0.83; 95% CI, 0.72-0.96). However, there were no differences in the cesarean delivery rate, chorioamnionitis nor prolonged length of stay.