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Survey of obstetric and gynecologic hospitalists and laborists

      Objective

      The objective of the study was to obtain descriptive information about obstetricians/gynecologists who currently are practicing as hospitalists or laborists.

      Study Design

      A survey was emailed to all actively practicing member Fellows of the American College of Obstetricians and Gynecologists in April 2009. A second emailing of the survey was sent in May 2009.

      Results

      Obstetrician/gynecologist hospitalists and laborists are significantly younger than the rest of the obstetrician/gynecologist sample by age and years in residency and have a high rate of career satisfaction. There was a great deal of variation in work schedules and compensation of the respondents.

      Conclusion

      We analyzed the rapidly growing hospitalist/laborist model of care within the obstetrician/gynecologist specialty. The laborists and hospitalists model provides an alternative type of practice for obstetricians/gynecologists, and it is associated with high career satisfaction. It is important that we continue to monitor the needs of this burgeoning field of clinical practice.

      Key words

      Health care has seen a dramatic shift in how inpatient treatment is delivered with the emergence of internal medicine physicians and pediatricians who work as hospitalists.
      • Freed G.L.
      • Dunham K.M.
      Research Advisory Committee of the American Board of Pediatrics
      Pediatric hospitalists: training, current practice and career goals.
      • Wachter R.
      • Wachter R.M.
      • Goldman L.
      The emerging role of hospitalists in the American health care system.
      The laborist model was first described in 2003 as a physician whose sole focus of practice is treating the patient in labor.
      • Weinstein L.
      The laborist: a new focus of practice for the obstetrician.
      The “individual is available on the delivery floor to provide prompt, continuous, and efficient care to the laboring patient or to the patient who needs evaluation for an obstetric problem.” It was argued that a laborist system within the field of obstetrics/gynecology would decrease workload, increase job satisfaction, provide better patient care, and lead to decreased malpractice liability for hospitals.
      • Weinstein L.
      The laborist: a new focus of practice for the obstetrician.
      For Editors' Commentary, see Table of Contents
      Since that publication, there have been many news articles on this subject.
      • Goldstein J.
      As doctors get a life, strains show.
      • Yates J.
      The laborists are here, but can they thrive in US hospitals?.
      • Hobson K.
      Division of labor, there's a new doc in town But mom probably won't meet this obstetrician until her labor pains start.
      These articles highlighted the rationale of a hospitalist/laborist system of practice and focused predominantly on physician career satisfaction, flexible work schedule, and patient acceptance. However, to date there has been no description of the hospitalist/laborists workforce: their work schedule, the care they provide, their compensation, or their practice environment.
      With this rapidly changing practice environment, our goal was to elicit descriptive information about the individuals and their practice patterns as laborists/hospitalists. We hypothesized the study would identify a high level of career satisfaction of actively practicing obstetrics/gynecology hospitalists and laborists. Additionally, we hypothesized that more women would be working in this type of practice than men.

      Materials and Methods

      An electronic survey that consisted of 20 questions was emailed to all 28,545 actively practicing Fellows of the American College of Obstetrics and Gynecology in April 2009. A second emailing was sent in May 2009 to increase the response rate. The survey was developed in coordination with the authors in this study and approved by the American College of Obstetricians and Gynecologists institutional review board.
      The first component of the survey consisted of 5 questions that detailed basic demographic information. The sixth question asked the respondent if he/she considered him/herself to be an obstetrics/gynecology laborist, obstetrics/gynecology hospitalist, or neither. Obstetrics/gynecology laborist was defined as an individual who cares for obstetric patients on labor and delivery only. An obstetrics/gynecology hospitalist was defined as a person who cared for obstetric, gynecologic, and obstetrics/gynecology patients in the emergency department. If the “neither” option was selected, the survey promptly ended with a note thanking the participant for their time. If the obstetrics/gynecology laborist or hospitalist option was selected, the survey continued with an additional 14 questions that detailed work schedule, care provided, career satisfaction, practice environment, and compensation.
      The obstetrics/gynecology laborist and hospitalist respondents were asked an open-ended question about the number of shifts per week and hourly length of shifts. Responses to open-ended questions were evaluated by 2 researchers who were blind to respondents' demographic information. Full-time vs part-time employment status and availability of moonlighting and working additional shifts for extra pay was asked. Information about type of care provided was ascertained and included information about routine coverage for postpartum patients and type of patient, obstetric or gynecologic emergency that required >50% of the physician's time.
      Career satisfaction was rated on a scale from −5 to +5, where −5 represented “very dissatisfied”, 0 represented “neutral,” and +5 represented “very satisfied.” Number of deliveries per year at the participating hospital, number of deliveries per year performed by the hospitalist group, and presence of a residency program within the hospital were asked within a range of common volumes. Information regarding the amount of annual cash compensation, approximate hourly rate, and benefits provided was requested. The importance of 5 common benefits could be rated as not important, somewhat important, and very important.
      Data were analyzed with a personal computer-based version of SPSS software (version 16.0; SPSS Inc, Chicago, IL). Descriptive and frequency data were computed for primary analysis. One-way analysis of variance was used for continuous variables; χ2 analyses were conducted for categoric variables. Significance was evaluated at alpha < .05 and confidence intervals of 95%.

      Results

      Of the 28,545 clinicians who were contacted, 339 clinicians had invalid email addresses; 7044 clinicians responded, which yielded a response rate of 25%. Of the respondents, 1020 clinicians (15% of respondents, 3.6% of the entire sample) described themselves as obstetrics/gynecology hospitalists or laborists and completed the extended survey.
      The mean age of all responders was 50.4 years; the mean years since completion of residency were 18.9. Hospitalists and laborists are significantly younger than the rest of the obstetrician/gynecologist sample by age (F1,6842 = 58.1; P < .001) and years since residency (F1,6916 = 82.4; P < .001), when we controlled for gender in each case (Figure 1). The mean age for the hospitalists and laborists group is 48.8 ± 10.2 (SD) and the nonhospitalists and nonlaborists group is 50.6 ± 10.3. The mean years since residency for the hospitalists and laborists group is 17.0 ± 10.7 and the nonhospitalists and laborists group is 19.22 ± 10.5. Forty-five percent of the respondents were female. In regards to gender, there were no significant findings pertaining to full-time or part-time employment or compensation. Over one-half of the hospitalists and laborists (51.5%) were from American College of Obstetricians and Gynecologists district IV (17.6%; District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia, West Virginia, Puerto Rico, and the West Indies), district VII (21.7%; Alabama, Arkansas, Kansas, Louisiana, Mexico, Mississippi, Missouri, Oklahoma, Tennessee), and district VIII (12.1%; Alaska, Alberta, Arizona, British Columbia, Central America, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, Wyoming, American Samoa, Guam, Northwest Territory, Yukon Territory). The top 3 employer models for hospitalists and laborists were hospital systems (31.7%), single specialty medical groups (26.3%), and obstetrics/gynecology hospitalist groups (25.1%).
      Figure thumbnail gr1
      FIGURE 1Years since completion of residency (P < .001)
      Funk. Survey of obstetric-gynecologic hospitalists and laborists. Am J Obstet Gynecol 2010.
      Eighty-two percent of the hospitalists and laborists were working full time. There was a great deal of variation in the length of shifts; many providers responded with a range of hours. The median range that was listed was 16 hours; the most commonly reported ranges were 24 hours (30.8%), 12 hours (22.5%), 8 hours (9.4%), and 18 hours (8.7%). The maximum length of shift that was listed was 48 hours. Sixty-two percent of the respondents work in hospitals that allow moonlighting.
      The median number of shifts per week was 3.5. Again, there was a great deal of variation with respondents listing a range of shifts per week. Most respondents (65.5%) worked ≤3.5 shifts per week. The most common response was 2 shifts per week (88%).
      Eighty percent of the hospitalists and laborists stated that they spent more than one-half of their time caring for obstetrics patients. Eighty-five percent of them provided routine coverage for postpartum patients.
      When asked about their career satisfaction, most hospitalists and laborists answered that they were satisfied; 76% of them answered +3 (131 respondents), +4 (204 respondents), and +5 (212 respondents). Only 8% of those who indicated their level of career satisfaction were dissatisfied (n = 59 respondents; Figure 2).
      Figure thumbnail gr2
      FIGURE 2Career satisfaction among hospitalists and laborists
      Funk. Survey of obstetric-gynecologic hospitalists and laborists. Am J Obstet Gynecol 2010.
      There was a relatively equal distribution of the number of deliveries per year at the hospital in which the laborist or hospitalist was working (Figure 3). Of those who responded to this question, 37.3% of the respondents worked at institutions that performed >3000 deliveries yearly; 18.7% of the respondents worked at institutions with 2001-3000 deliveries yearly; 21.9% of the respondents worked at institutions with 1000-2000 deliveries yearly, and 22% of the respondents worked at institutions with <1000 deliveries yearly.
      Figure thumbnail gr3
      FIGURE 3Number of deliveries at participating hospital
      Funk. Survey of obstetric-gynecologic hospitalists and laborists. Am J Obstet Gynecol 2010.
      There was a large contrast in approximate annual compensation. Approximately one-half of the respondents (52.7%) earn <$200,000 per year; 29.3% of the respondents indicated “<$151,000.” Fewer than 10% of the respondents stated that they earned >$300,000 per year (9.2%).
      The benefit most commonly provided was professional liability insurance (80.2%). It was also the most important benefit to be offered; 91.5% of the respondents stated that the importance of professional liability insurance being offered was “very important.” More employers provided vacation (73.1%) than health insurance (71.8%). However, 85.5% of the physicians stated that health insurance was very important to them; only 77.6% of the physicians stated that vacation was very important. Of the remaining benefits, 57.8% of the physicians were provided life insurance; 55.5% of the physicians were provided disability insurance, and 67.4% of the physicians were provided continuing medical education benefits. Based on percentages of respondents who stated the benefit was very important to them, the benefits most desired (in order of importance) were professional liability insurance, health insurance, vacation, disability insurance, continuing medical education, and life insurance.

      Comment

      With the dramatic changes in healthcare delivery, renewed interest in work-hour restrictions, and increased focus on evidenced-based medicine, the hospitalist and laborist movement appears to be maturing. This survey was an attempt to identify those clinicians who currently are engaged in the hospitalist or laborist model of care. Fifteen percent of those who responded described themselves as hospitalists or laborists, which highlights the importance of examining this burgeoning field of healthcare delivery.
      One of the most remarkable findings of this study was the high career satisfaction among those clinicians who work as hospitalists and laborists. High career satisfaction is not typical in the obstetrics/gynecology specialty. As many articles have detailed and studies support, there is an increasing workload and decreasing career satisfaction among practicing obstetricians and gynecologists.
      • Weinstein L.
      The unbearable unhappiness of the obgyn: a crisis looms.
      • Schauberger C.W.
      • Gribble R.K.
      Best practices for call to make for a sustainable career.
      • Bettes B.A.
      • Strunk A.L.
      • Coleman V.H.
      • Schulkin J.
      Professional liability and other career pressures: impact on obstetrician-gynecologists' career satisfaction.
      • Bettes B.A.
      • Chalas E.
      • Coleman V.H.
      • Schulkin J.
      Heavier workload, less personal control: impact of delivery on obstetrician/gynecologists' career satisfaction.
      • Anderson B.L.
      • Hale R.W.
      • Salsberg E.
      • Schulkin J.
      Outlook for the future of the obstetrician-gynecologist workforce.
      • Dresden G.M.
      • Baldwin L.M.
      • Andrilla C.H.A.
      • Skillman S.M.
      • Benedetti T.J.
      Influence of obstetric practice on workload and practice patterns of family physicians and obstetrician-gynecologists.
      This survey suggested that the opportunities in this field are attractive to a wide variety of obstetricians/gynecologists. Desirable aspects of this model, as opposed to a more traditional obstetrics/gynecology practice model, include regularly scheduled shifts, more control in the work hours, and guaranteed time off.
      • Weinstein L.
      The laborist: a new focus of practice for the obstetrician.
      • Bettes B.A.
      • Chalas E.
      • Coleman V.H.
      • Schulkin J.
      Heavier workload, less personal control: impact of delivery on obstetrician/gynecologists' career satisfaction.
      This could also account for the findings that obstetrics/gynecology hospitalists and laborist are younger than the rest of the obstetrics/gynecology sample by age and years in residency.
      • Dorsey E.R.
      • Jarjoura D.
      • Ruteck G.W.
      Influence of controllable lifestyle on recent trends in specialty choice by US medical students.
      On further review of job satisfaction, there were no significant findings regarding satisfaction that were related to salary compensation and full-time or part-time employment. It has been shown that the ability to control the schedule or decreased variance in the daily schedule is an important component of the high career satisfaction in medicine. The flexibility in the laborists and hospitalist positions may appeal to obstetricians/gynecologists who are dissatisfied with the work schedule.
      • Bettes B.A.
      • Chalas E.
      • Coleman V.H.
      • Schulkin J.
      Heavier workload, less personal control: impact of delivery on obstetrician/gynecologists' career satisfaction.
      • Dorsey E.R.
      • Jarjoura D.
      • Ruteck G.W.
      Influence of controllable lifestyle on recent trends in specialty choice by US medical students.
      Having identified those benefits that were most desired by the respondents, employers could use these data to improve recruitment and retention of physicians by offering enhanced compensation packages.
      Given the equal distributions on many of our variables, the results suggest that there is little consistency in the characteristics of hospitalists/laborists work. Other than most of the laborists and hospitalists reporting high satisfaction, there was a great deal of variation in the type of environment, the number of deliveries, or the level of compensation among the hospitalists/laborists who responded to our survey. The finding of so many dissimilar models of care may make it difficult to demonstrate the effect of a laborist model on quality and patient safety parameters in future research.
      There were several limitations in this study. An adequate but low response was obtained from the 28,545 physicians. Although they were told that the survey was about hospitalists and laborists and that it would be very brief, some obstetricians/gynecologists may not have completed the survey because they did not think it pertained to them or they did not have time. Also there was no incentive, other than contributing to the research. Despite this low response, the information that was provided by the respondents in this study was a valuable first look at a topic about which very little is known.
      Some respondents who continued the survey were clearly not working as a dedicated laborist or hospitalist as it had been defined; thus, some of the results were confounded. As anticipated because of the open-ended format of the questions, there was a large variety of responses regarding the shift length and days worked per week. This most likely represents the diversity of programs that currently are operating.
      Our counterparts in internal medicine and pediatrics have witnessed a rapid growth of the hospitalist model of care.
      • Freed G.L.
      • Dunham K.M.
      Research Advisory Committee of the American Board of Pediatrics
      Pediatric hospitalists: training, current practice and career goals.
      • Wachter R.
      • Wachter R.M.
      • Goldman L.
      The emerging role of hospitalists in the American health care system.
      The information obtained in this study is a quantitative look at the hospitalist and laborist movement, which has grown to include 15% of the obstetrics/gynecology physicians who responded to this survey. This is an important new option in the obstetrics/gynecology specialty that gives doctors an alternative choice of practice that may lead to a more sustainable career with high job satisfaction. Given this new information, it would be advantageous to continue to monitor the practice of this rapidly growing field within the obstetrics and gynecology specialty.

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