hospital birth, Physician Training

Who Will be Delivering Babies in the United States in Coming Years?

The American College of Obstetrics and Gynecology (ACOG) estimates that the U.S. will have between 6,000 and 8,800 fewer ob-gyns than needed by the year 2020.  Additionally, there is a possible shortage of 22,000 by the year 2050. 

What is being done about this problem?  Well, there are currently efforts to attempt to increase the number of residency positions.  There is also talk of having nurse midwives take a greater role.  While those are valid interventions, let’s take the issue much deeper, as that is certainly not doing enough to mitigate the problem.  Perhaps of equal or greater importance in the consideration should be retaining practicing ob-gyns and malpractice reform.

 The current work force in Obstetrics and Gynecology is aging, retiring early, and going part time at an increasing pace, all while the number of patients seeking care is exploding due to health care reform and population statistics.  While access to maternity care and women’s health services is vitally important, we need to have infrastructure to support the numbers or these women will have no ob-gyn to turn to despite having insurance. Even if the number of residency spots increases, the attrition of those already in the field must be addressed.

 Today, over 80% of physicians entering the field of ob-gyn are women.  Shockingly, if you look at hospital department chairs, academic medical institutions, and leadership positions in the field it is overwhelmingly male despite the preponderance of women who are practicing and are the future of ob-gyn. In order to appropriately assess the changes and adjustments that need to be made to the field, including what will draw in and retain candidates, we should be asking that very demographic that is accounting for the majority of ob-gyns. This means that women need to be “at the table” for discussions and interventions impacting our field. Women want to be invited to be a part of the change and are willing to step up to the challenge.

 As for malpractice reform, this is vital not only to obstetrics and gynecology, but the entire medical system.  Defensive medicine is valuable to no one and a waste of precious health care dollars.  In addition, increasing numbers of midwives to assist with a shortage will only be helpful if ob-gyns are willing to provide a supportive role.  As it is now, ob-gyns can named in a lawsuit by malpractice attorneys who seek damages for birth injury cases where a labor occurred at home.  These patients often arrive at the nearest hospital’s doorstep seeking help after a failed home birth or bleeding concerns. The attending ob-gyn physician must (and should) accept care for anyone arriving seeking help.  However, if there is a bad outcome, it must be somehow proven when damage occurred.  Was it during the unmonitored 30+ hour home birth or the 30 minutes from when the patient arrived to the hospital prior to an emergent cesarean?  Obviously, no one wants a poor outcome for the patient and blaming each other is not a solution.

 A solution is malpractice reform where a physician does not need to worry that if they are called to help in a complicated case that they will now be liable for whatever happened prior to their involvement with care. Certified nurse midwives, especially those working in a hospital or birthing center, will likely have a huge role moving forward in our field. There are many fantastic midwives who bring valuable assets to the table.  Ob-gyns should be willing and ready to work as a team for improved patient outcomes. 

 Lastly, malpractice reform is important because rising malpractice premiums are a huge part of why private practice ob-gyn is becoming a thing of the past. Understandably, it is hard for a practice to survive while paying $80,000 for yearly malpractice premiums, then staff, then rent for office space.  Somewhere the ob-gyn is expected to make a living, but the private practice ob-gyn is struggling. This is why new residents accepting jobs are looking for employed positions which will provide tail coverage and protection from this concern. While employed positions certainly have their benefits, one of the major drawbacks we are seeing is loss of physician autonomy and control over our field.

 Moving forward, physicians need to have a larger voice in reforms that are taking place in health care. Especially in the field of ob-gyn, female physicians need to be an integral and valuable asset to improving the field by working alongside the people currently contributing to the changes.  While the voices from our government, lawyers and insurance companies are important and necessary, they should not be muting the voices of the physicians who are the ones providing care for our patients and have the patient’s best interest most at heart.  This communication will be vital in continuing to have a robust ob-gyn work force ready to handle an increasingly complex and high risk patient population in the United States.

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hospital birth, Parenting, Physician Training

When Dads Cry During the Delivery

He is pacing. He is nervous. This is his first baby and he is scared to death. His wife is getting settled into the delivery room with fetal monitors being applied.  The nurse is asking health history questions in between her painful contractions and quickly places an IV and draws labs. The soon-to-be new Dad pretends to busy himself with setting up pillows and figuring out how to work the fold out chair that will serve as his bed if he can even consider sleeping at some point during the process.

I start to discuss the routine hospital consent for delivery.  We review the real risks of possible maternal injury: blood loss, infection, or need for surgery or other medical interventions.  We also talk about fetal risks.  He is listening attentively and his wife looks to him for reassurance before she signs the papers.  He gives a quick nod and places his hand on her back.  For a second he feels useful, she needs him to be her advocate and he is grateful to have this role.

We talk about the actual delivery and any preferences.  He looks a little squeamish when I ask him if he wants to cut the umbilical cord at delivery and he politely declines.

Over the next few hours an epidural is placed and the labor progresses quickly.  She is ready to begin pushing.  He stands by her side, holding her hand and applying a cool cloth to her forehead.   She is getting exhausted after over 2 hours of pushing and he is starting to fidget.  Concern is evident on his face as he keeps looking at my eyes behind my mask for reassurance.  I tell them both she is doing great.  Baby is fine.  All is well.

He is her protector, but presently is left feeling utterly helpless.  His entire life, and all things that ultimately matter to him in this world, are out of his control.  He starts pacing again, breathing a little more rapidly but keeping it together to appear calm for his wife.  She needs him to believe everything is fine. She needs him to be her rock at this moment. She grips his hand with all her strength and finally the baby delivers.  The umbilical cord is wrapped tightly around the baby’s neck twice.  I calmly ask the mother to stop pushing and untangle and quickly remove the cord from around the baby’s neck.  The rest of the baby’s body delivers and a small squeak emerges from the baby boy right before his loud bellowing cry.  The mother realized she has been holding her own breath while waiting to see if her baby is ok and she inhales deeply with relief, gratitude, and amazement at what just happened. 

I look over to Dad.  He is crying.  Actually sobbing.  The experience is like nothing he could ever have imagined. He clenches his wife’s hand so tightly that it turns white.  He kisses her sweaty forehead and leans his head into the crook of her neck.  His love for his wife and newborn baby is palpable.

My own eyes are welling with tears.  It is not lost on me the utter importance of this moment in their lives.  It also comforts me to know how much this baby will be loved.  I ask one more time if Dad would like to cut the umbilical cord, a second chance to take part in this tradition.  This time, Dad shakes his head yes.  He walks over and his trembling hands grab the scissors and cut through the surprisingly tough and gummy umbilical cord. I quietly complete my routine assessments of blood loss, deliver the placenta, and help to make sure Mom is now comfortable. 

Before parting, I give Mom a hug as we have become close over the past 9 months with frequent visits and I have come to know her very well.  I shake Dad’s hand and congratulate him one last time.  His eyes meet mine and he holds my grasp an extra second.  He doesn’t say an additional word but his unspoken gratitude speaks volumes to me.

Physician Training

Choosing OB/GYN as a Specialty

As a medical student, I had already known I would pursue a specialty in OB/GYN prior to the new student orientation.  However, many physicians and mentors recommended I keep my options open when going through clinical rotations in other fields.

Neurology and radiology were surprisingly interesting to me.  However, the variety that comes from the specialty of OB/GYN was paramount in my decision.  The ability to perform surgery, do routine office visits, deliver babies, and see patients of all ages guarantees days that are free of boredom and monotony.

For medical students or practicing OB/GYN’s the following factors are paramount in decision making regarding your career:

1.       The field is changing dramatically.  There will likely soon be a shift from a generalist OB/GYN to separating out the specialty to office practice, “laborist” (hourly employed position solely devoted to obstetrics), GYN surgery.  In fact, this is already happening with large HMOs that employ increasing numbers of OB/GYN’s.

 The reasons are multifactorial.  It is now becoming crucial to have an immediately available “in house” obstetrician to manage emergencies, delivery complications, patient expectations.  In fact, it is the norm now for most hospitals, and from a risk management perspective it is becoming a must.

GYN surgery is also rapidly evolving.  It is essential to keep up with new techniques and also have an adequate case load to keep surgical skills at an optimal level.  It is extremely difficult to do this while also maintaining a busy obstetrics practice.

2.       Malpractice premiums.  This has changed the specialty from one comprised of private practices to employed positions.  The risk of being sued at some point in your career is unfortunately expected.  This is regardless of fault.  Most lawsuits never make it to trial due to lack of medical negligence.  However, the stress of being named in a lawsuit is independent of this factor.  Luckily, I have never gone through this but know MANY colleagues who have.  In an employed position you are covered for malpractice.  In addition, the salaries tend to be higher- especially when first starting out from residency.

 3.       Student debt.  You need a way to pay it off!  OB/GYN is a specialty that will help you do this quickly.  The average salary remains good and an amount that is certainly enough to pay off debt assuming one doesn’t live above their means immediately after accepting first position.

4.       You must love the “highs” you get from a job well done.  Let’s be honest….what can be more gratifying than being a part of a family’s most important day of their lives as you safely deliver their child.  Or performing a surgery that gives a woman a functioning life back. Or guiding a woman through miscarriage or infertility.  This gets you through the sleepless nights and late days in the office.  This makes up for the frustrating medical documentation and checklists.  This can help buffer the onslaught of requests and regulation from administrators who may or may not even be in the medical field.  You have to be unable to imagine doing anything else!

retirement

Retired at 37: Breaking Up With a Career in Medicine

Leaving your career in medicine is like breaking up in a long term relationship.  It may have all started out with lofty expectations, excitement about the future, and becoming your best self.  However, somewhere along the way things got messy and twisted and not what you signed up for.

There were hiccups along the way, signs that maybe it wasn’t good for you. There was the time you fell asleep at the wheel and totaled your car on interstate 95.  You were in a daze, driving home after 30+ hours awake delivering babies, doing surgeries, and rounding on patients in the hospital. You walked away fine but the car was demolished. It was scary, but not enough to make you leave.  It was like a big fight in a relationship.  It made you realize your shortcomings and problems with a system that encourages working in unsafe conditions, but you decide it was just a mistake. Next time you’ll sleep at the hospital first before heading home. You think it is your fault and can’t be the relationship that is broken.   

Or perhaps, the time when you were in your first year of obstetrics training.  Your hands were shaking from adrenaline after a tough delivery. You breathe a sigh of relief when the baby’s limp body begins to move and he gasps for air.  You attempt to obtain blood from the umbilical cord for testing.  A large bore needle sliced its way through the flimsy protection of a rubber glove as you clumsily tried to obtain the sample. You were acutely aware that your patient has HIV.  What was her viral load?  Your head spins and suddenly you feel nauseated. Now you were potentially exposed to HIV through a needle stick.  You take the antiretroviral medications prescribed to decrease your exposure risk of HIV despite the toll it takes on your body.  You can barely complete your busy days in residency due to the nausea and fatigue from the medications.   Thankfully, it works.  After follow up testing for over a year, you are cleared from the infectious disease physician and no longer need to worry about the exposure. You think to yourself, this is just a test of my commitment. There are risks with being a doctor, ones we agree to accept. Just as you risk opening yourself to heartbreak in a relationship by giving of yourself.  In medicine, you do the same.  It is for a greater purpose.  You acknowledge the risk and forge on.

There were happy times too.  The day you emergently took a woman with a ruptured ectopic pregnancy to the operating room, her abdomen filled with a liter of blood.  You transfused life-saving blood while swiftly removing the fallopian tube that had been irreparably damaged.  Your patient hugged you afterward for saving her life and you discuss getting pregnant in the future.  Two years later you embrace again, in celebration of a healthy pregnancy now growing safely in her uterus.

Or the time you discuss infertility with a patient, handing her tissues and listening intently while she tearfully describes her years of inability to get pregnant- the one thing she desires more than anything in this world. You discuss risks and benefits of a medication to enhance ovulation and review next steps.  She returns several months later, absolutely beaming and you confirm her pregnancy.  This is why you went into medicine.

The good times keep you going, holding on.  Plus, there were the expectations and investments put into this relationship.

Now it’s been 7 years in a busy Obstetrics and Gynecology practice. You made it through 3 of your own high risk, complicated pregnancies. You have hit your stride in practice.  Confident in your skills, comfortable with your decisions, and patients are waiting to see you. You are doing all of the right things but something has changed.  Is it you?  Is it the relationship?

You notice that increasingly over the last few years, health care has changed.  Hospitals, administrators, employers, and even patients all seem to have a more powerful voice in the field of medicine than physicians.  Physicians who have tirelessly devoted themselves to patients, often at the expense of their own families, are being marginalized. Expertise is being overlooked for cost effectiveness, “patient satisfaction scores”, and computerized check lists. Your love for the medicine has not changed, yet somehow everything surrounding it has.

The years invested in training amounted to 8 years after undergraduate school.  In residency training you worked over 80 hours per week for little more than minimum wage. The debt incurred from medical school was enormous.  You can’t just walk away.  This is a commitment. You made a promise.

Change is hard.  Especially when you have invested so much. You have lost years of time with your family and friends.  You missed weddings, funerals, birthdays. You feel pressure that the noble thing to do is “stick it out” and not complain.   No one wants to hear a doctor complaining about their job.

It takes a personal health scare to make you realize that you actually do matter.  Your happiness matters.  Your family and time are important.   The only way to recapture yourself is to leave medicine.  You decide to leave this destructive relationship when you realize that you are not the problem.  You are not “burned out”.  The problem is the current environment in medicine which puts physicians last on the list.  Your stories are not unique, and all too common amongst others in the field.  Leaving for you is taking control back. Control of your life and also making a statement for those still in this unhealthy relationship. You join the increasing ranks of young physicians that are finally taking a stand and demanding better from this toxic relationship.