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Emergency Medicine Residency Programs

In a few select areas of the country. ob.gyn. hospitalist programs are starting up, a trend motivated not just by the malpractice crisis, but also by lifestyle issues and the need to run ob.gyn. practices more efficiently.

The concept of ob.gyns. working exclusively in the hospital has been around for a long time, but terming them "hospitalists" is a recent development, Roger Heroux, who owns the consulting firm Hospital Management Associates in Colorado Springs, Colo.

The Society of Hospital Medicine, the trade organization for inpatient medicine, does not have complete records of how many ob.gyn. hospitalists there are in the country. "Since this is such a new thing, we're not sure how groups really classify themselves as subspecialists in this area at this time," said Lisa Freeman, a society spokeswoman.

"More and more hospitals are going to be setting up ob.gyn. hospitalist programs," Mr. Heroux predicted.

Washington Hospital in Fremont, Calif., established such a program in January. It recruited ob.gyns, to work in the hospital, doing labor and delivery and covering the emergency department.

As a condition of privileging, many hospitals require private ob.gyns. to be on call for emergency care and unassigned patients. This raises a number of issues, said David Joyce, president of Delphi Healthcare Partners, a consulting and contract medical management firm in Durham, N.C., that designed the program for the California hospital.

"Some obstetricians don't want to take care of patients in the emergency department anymore," he said. "If a patient walks in with no prenatal care, that's a tremendous malpractice risk."

Scheduling time to attend to patients is another big problem. "If you're seeing patients in your office, already doing surgery and have two other patients in labor, you can't be in three places at one time," he said.

At Washington Hospital, the four full-time physicians recruited by Delphi work in shifts, so that an ob.gyn, is at the hospital 24 hours a day. Each works only 42 hours a week. "This means if an unassigned or indigent patient comes into the emergency department, the hospitalist takes care of them, instead of calling a private obstetrician," he said.

The hospitalist gets to the problem sooner, said Dr. Albert Brooks, medical director of Washington's ob.gyn, hospitalist program. "By having an ob.gyn, in the hospital 24 hours a day, we can get there in 5 minutes and manage a patient's bleeding and heart rate, while the private ob.gyn, is rushing to the hospital."

Delphi arranges the malpractice insurance for the hospitalists and handles billing, collections, and credentialing.

As far as keeping malpractice costs in line, "Delphi can only buy malpractice insurance from companies in the open market, just like everyone else," Mr. Joyce said. "We're a decent-sized company, so we'll probably get better rates than the average hospital or physician." The bottom line is the cost is going to be there whether the hospital, physician, or a consultant does it, he added.

Delphi's next project is in Salem, Ore., an area that needs hospitalist obstetricians to do backup for family physicians delivering babies, "because the private obstetricians don't want to," Mr. Joyce said.

To his knowledge, Washington Hospital has the only "pure" ob.gyn. hospitalist program in the country, "but that's not to say that other hospitals aren't using [other] models to accomplish the same thing."

Some have variations for covering the emergency department. Mr. Joyce said. For example, Alta Bates Summit Medical Center, a large teaching hospital in Alameda County, Calif., employs "ob. generalists" who function much like residents. These physicians "help in labor and delivery and do some of the more menial tasks in support of the private obstetricians," he said.

Other hospitals in the San Francisco bay area have arrangements where private ob.gyns. stay in-house on weeknights and weekend nights on a rotating basis. This is different from the ob.gyn. hospitalists, "who only do hospital work. They do not have a private practice."

The malpractice burden isn't always the motivator for choosing a unique practice setting. For Dr. Mark Hathaway, an ob.gyn. at the Washington Hospital Center in Washington, D.C., it was a desire to expand the health care safety net. Seven years ago, after his residency, he set up an arrangement with Unity Health Care Inc., a nonprofit agency that offers medical care to underserved patients in the Washington, D.C., area. All of his clinic hours are spent in one of Unity Healthcare's clinics, he said. In turn, "Unity Health Care pays the hospital a portion of my salary."

This collaboration between hospital and clinic has since expanded into a practice that includes seven ob.gyns. and more than four midwives, providing ob.gyn. services to 11 Unity Health Care clinics in the District of Columbia.

For physicians who want to work in underserved clinics, "it's the ideal situation," Dr. Hathaway said. In addition, "our malpractice is covered by the hospital center," he said.

BY JENNIFER SILVERMAN

Associate Editor, Practice Trends

COPYRIGHT 2004 International Medical News Group
COPYRIGHT 2004 Gale Group