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.
Family Physicians can deliver babies.
Female OB in practice 25 years here…
There will be a crisis of OB/Gyns as those who enter the field realize it is the most difficult and self- sacrificial career choice. Employed physicians have no autonomy and their schedules are packed with patients . The visits, labs, phone calls and now emails generated in the office means 2-3 hours of work after hours. Thay’s personal time, time that would have been with family or for exercise. Then there is call, which involves increasingly higher risk patients, hours on labor & delivery, vaginal deliveries and cesareans at all hours. At the same time the OB is covering the ED for consults and may have a possible trip to the OR for surgery (think ectopic). These exhausting calls recur with minimal recovery between them. As more and more OBs leave the field for burnout, the remainder progressively burn out, thus fueling the crisis.
Malpractice plays a role in stress, but not in the daily life of an OB/Gyn.
Interesting that you completely left family physicians out of your calculations, but included the much less trained nurse-midwives. The same reasons Obstetricians burn out and go to strictly Gyn practice affect family physicians. Malpractice insurance costs in some states are overwhelmingly prohibitive and family physicians are typically paid less per RVU (if employed) vs OB for same vaginal delivery. These factors add to residents’ hesitancy to even proceed with that part of training.
Family physicians would be a much welcome (and respected) resource. I do admit my ignorance in how much malpractice costs are for family physicians but I assume it adds quite a bit to liability when deciding if this will be included in your scope of practice. Unfortunately, in my part of the country and the hospitals where I have worked, family physicians do not want to perform deliveries for exactly the reasons you mentioned. In addition, often large practices and/or employers will actually not allow their family doctors to utilize their skills and care for pregnant patients/deliver babies as they do not want to pay for the increase in premiums. I imagine this is quite different in rural areas where family physicians are heavily relied upon and sought out for maternal care.
I practice in a small community in rural north Louisiana in a group of Three board certified obstetricians who are now the only providers delivering in a three parish area. When I began my practice in 1992 there were several family physicians delivering in two nearby rural towns and even one in my town. They did a fine job, but the realities of the medical malpractice risk drove them out of the business of delivering babies because the could not provide immediate access to a cesarean delivery if things went bad as we (their back-up) were more than 30 minutes away. The recommendation that delivering facilities must be able to provide emergent cesarean delivery, rather real or perceived, has been taken literally by defendant attorneys and jury’s. Now those patients must all travel for their prenatal care, which is prohibitive for many, and hope they reach their delivery destination before it is too late. I see the malpractice risk as the largest detractor for non obstetricians providing this care. The enjoyment and reward (non monetary of course) would be suffucuent for most providers to offer this service in a risk free environment. It is a very easy problem to fix in my simple mind.Go to a no fault compensation system where a panel of professionals could fairly compensate injured patients and sanction obviously incompetent providers. This would immediately cut a third off the health care dollars spent, taking it from attorneys and their paid “experts” and take away the fear all practioners have of a rediculous reward that will bankrupt and shame them while making an undeserving Attorny rich. I’m just saying! Why is nobody in politics talking about this?