Chapter 4: Performance of OB/GYN Hospitalist Programs

INTRODUCTION

In 1899, John Whitridge Williams succeeded Howard Kelly as the obstetrician-in-chief at the Johns Hopkins Hospital in Baltimore, Maryland. Interestingly at that time, the departments were separated into two, with Dr. Kelly remaining head of the gynecology department and Williams becoming head of the obstetrics department. Although Williams was opposed to this division, he immediately began organizing his department on scientific principles. With the production of William's Obstetrics in 1903, the course of American obstetrics changed to coalesce and document the science of childbirth, with the author referencing over 1100 publications in its original edition.¹ Despite the efforts of Williams, the field of OB/GYN failed to win legitimacy by other physicians for what was instead thought of as a role for “skilled laborers” as opposed to true consultants.² In 1957, Dr. J. A. Rene Simard lamented, “Obstetrics … still remains, in the minds of many, a poor relation of medicine and surgery. Sometimes a good friend will repeat the sally: ‘If your son is intelligent, let him be a physician; if he is clever, let him be a surgeon; if he is neither, let him be an accoucher (obstetrician).’”

Clearly, times and attitudes have changed. The increasing complexity of medicine has increased the number of fields of specialization, and the gap between generalist and consultant continues to widen. This trend also applies to OB/GYN. Radiologists, emergency department (ED) physicians, and anesthesiologists are wary of pregnancy and the complex situations presented by a gestation. Faced with increasing specialization, many view the work of the OB/GYN specialist as a critical and highly skilled role that is necessary to optimize outcomes and avoid litigation. There is a further push toward having a specialist in labor and delivery (L&D)—the OB/GYN hospitalist—to improve outcomes, strengthen safety efforts, improve overall work conditions, and enhance workplace efficiency.

The OB/GYN hospitalist is a new player in women's health and becoming thought of as critical as an important team member in the delivery of obstetric care. Beginning with the overall hospitalist movement in the 1990s, Wachter (1996) opined that the hospitalist movement would grow due to its aiding of care efficiency, and also theorized an improvement in providing value care.³ In 2003, Weinstein hypothesized that a physician whose sole focus would be to manage the patient in labor—that is, “laborists”—could provide a solution to the increasing malpractice liability, burnout, and a shortage of obstetricians.⁴ The role of the OB/GYN hospitalist already appears to be eclipsing these initially hypothesized roles. As patterns develop that define the role of the OB/GYN hospitalist as an integral team member with the generalist and maternal fetal medicine (MFM) specialist, the former will carve out a widening role and assume further authority in labor care.

THE OB/GYN HOSPITALIST AND ASSOCIATED CLINICAL OUTCOMES

The presence of hospitalists has led to dramatic care changes when employed in different specialties. Nonetheless, ...