Once upon a time it was expected that if you landed in the hospital, your primary care doctor would see you there. That's no longer typically the case. Since the 1990s, when so-called hospitalists – or dedicated inpatient physicians who provide medical care to hospitalized patients – emerged, their ranks have swelled to more than 50,000. Today, hospitalists see patients in most hospitals across the country.
The majority of doctors who have privileges at hospitals still practice in an outpatient setting – and come and go from the hospital. But the rise of the hospitalist – driven, in part, by an effort to cut hospital costs and to improve patient safety through standardization of care – reflects a movement toward having doctors whose full-time or primary focus is inpatient care. This comes amid concerns that many doctors, like those in primary care who see patients primarily outside hospital walls, are overextended by increasing demands on their time; the trend is also a response to a need for more in-house support to handle emergency care, and due to doctors' lifestyle preferences or the desire many clinicians have to be on-call less.
Following suit, a small but growing number of hospitals now use the services of OB-GYN hospitalists whose primary responsibility is to care for obstetric patients in the hospital, whether delivering babies or handling obstetric emergencies, such as postpartum hemorrhage, when a woman experiences heavy bleeding after she gives birth. The models vary: Some hospitals have OB-GYN hospitalists on staff; in other cases, doctors' groups arrange to have OB-GYNs cover deliveries at hospitals for a 12- or 24-hour period. While OB-GYN hospitalist is the most broadly recognized term today, the clinicians – depending on their responsibilities – are sometimes called laborists (focusing primarily on labor and delivery) or OB hospitalists, given their obstetric focus.
But the primary shift, experts say, is that OB-GYN hospitalists provide inpatient care that supplements or in some cases takes the place of care that's been traditionally provided by private practice OB-GYNs.
“We know that women in general would prefer to have their own physician that they've been seeing through their pregnancy to care for them. We're lucky, because 93 percent of our patients have early prenatal care – and excellent prenatal care,” says Dr. Allyson Brooks, executive medical director of the Women's Health Institute at Hoag Memorial Hospital Presbyterian in Newport Beach, California, which has an OB hospitalist program. “But many patients don't have prenatal care, and programs that have laborists in place – those patients don't have a preference – they just want a safe healthy delivery.”
Hospitals turn to OB-GYN hospitalist programs to provide round-the-clock inpatient care. “For the women who deliver at Hoag, we hope to provide a meaningful layer of additional patient care and support in labor that extends beyond back-up for potential emergencies,” says Dr. Tomekia Lynn Strickland, an OB-GYN hospitalist at Hoag. “In many ways, we are a hospital-based extension of the excellent care provided during their pregnancy by their primary OB/GYN.”
Most women who undergo regular prenatal care, still see their primary OB-GYN or someone else from that group on-call, when they give birth. But as with primary care doctors conceding time spent on inpatient care to general hospitalists, increasingly some OB-GYNs are deferring to OB-GYN hospitalists to reduce the time they need to spend in the hospital.
“I think that's one of the major problems is how do patients perceive the idea of just being delivered by someone they don't know?” says Dr. Edward Yeomans, chairman of the department of obstetrics and gynecology at Texas Tech University Health Sciences Center in Lubbock, Texas, and a maternal-fetal medicine physician.
“Obstetrics and gynecology was never designed to be a lifestyle specialty,” Yeomans contends. He says working “longer hours, and harder and off hours” to be there for the birth of a child, comes with the territory. “The idea of controlling your hours is one of the driving forces behind this hospitalist movement: You work a shift; and it's not compatible with my concept of why I went into OB-GYN.” But, Yeomans says he understands why some doctors would be drawn to that.
Experts say whatever the arrangement may be, it's important to discuss well in advance who is going to be available for the birth of a child.Yeomans tells his patients, “'If I am in town, I will come in for your delivery.' So that gives them some degree of confidence. I have speaking engagements, I'm away from the campus from time to time, I don't take much vacation, but really I'm available to them,” he says. “Whereas others who practice in a group practice would say myself or one of the group members will deliver you. So the woman has to be comfortable with that.”
In a 2016 committee opinion, the American College of Obstetricians and Gynecologists said it “supports the continued development and study of the obstetric and gynecologic (ob-gyn) hospitalist model as one potential approach to improve patient safety and professional satisfaction.” Though with various models of care and terms used for OB-GYN hospitalists, it can be difficult to track. ACOG noted that as of 2014, it's estimated about 1,700 OB-GYN hospitalists were working at approximately 10 percent of the hospitals in the U.S. that offer obstetric care, with one study finding about a quarter of community hospitals in California using OB-GYN hospitalists.
In regards to the potential impact on patient care, the opinion noted, “In one study, a dedicated ob-gyn hospitalist service was associated with a 27 percent reduction in the cesarean delivery rate as compared with the traditional model of care.” A separate study found a link between care managed by OB-GYN hospitalists in conjunction with certified nurse-midwives and a significant reduction in the C-section rate in comparison with a traditional OB-GYN care model. But the way the studies were designed, it wasn't possible to determine if the hospitalist approach was the cause for the decrease in C-sections. And individual OB-GYN hospitalist C-section rates can vary significantly, as is the case for other OB-GYNs. In general, ACOG notes, more study is needed to determine what impact care by OB-GYN hospitalists might have on patient outcomes.
Critics say what's potentially lost in the handoff from a primary OB-GYN to a hospitalist is personalization of care and a deeper understanding of what that patient might need. But though it takes effort to share patient notes and special care needs, those overseeing hospitalist programs say this is a top priority – and that having doctors dedicated to in-patient care extends what could be done by a primary OB-GYN, rather than detracting from care. OB-GYN hospitalists can, for example, provide immediate emergency services, so there's no need to wait for an on-call physician to arrive. “I think many patients want to choose hospitals that have a laborist program, because they feel that it has well thought out comprehensive care and they see that as a very positive thing,” says Dr. Manuel Alvarez, chairman of the department of OB-GYN and reproductive science at Hackensack University Medical Center in Hackensack, New Jersey, which has an OB-GYN hospitalist program.
Still as the model of care evolves, patient-doctor communication is critical to set expectations, experts say, to discuss well in advance what to expect – and who's going to be there – for the birth of the child.
To view the original U.S News & World Report article, please click here.
