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Editorial


Laborists, nocturnalists, weekendists: Will the “ists” preserve the rewards of OB practice?

Keep an eye on three new models of care that may alleviate burdensome aspects of obstetrics

September 2007 · Vol. 19, No. 09

Medical students often choose obstetrics and gynecology as a career because they experience the practice of obstetrics as remarkably fulfilling. The combination of continuity of care, medical and surgical challenges, and the joy of participating in childbirth is a major attraction to these students.

Historically, these attractive features of obstetric practice have been offset by a commitment to work exceptionally long hours. In fact, the American Medical Association estimates that OBs work about 60 hours a week1; in some locales, many work 80 hours or more a week.2

Many OBs are seeking to maintain their participation in those attractive aspects of obstetric practice that students embrace while reducing their total work hours—especially the hours committed to night and weekend shifts. Today, we’re witnessing the evolution of three new models of obstetric care that may offer a solution for this pressing challenge.

What’s your opinion on these new models?

Do you warm to the idea of alternative models of delivering hospital obstetric care? Add your point of view to the discussion by answering the INSTANT POLL on the homepage.

Enter the laborist…

The laborist model has developed from the observation that general internal medicine care can be successfully provided by a model in which so-called hospitalist physicians provide the in-hospital care of patients while a distinct group of office-based clinicians provide ambulatory care. That hospitalist model has been a great success in internal medicine, and appears to have improved both patient care and the work life of general internists.3

A basic tenet of the laborist model, therefore, is that differentiation of the practice of obstetrics into laborist and ambulatory divisions of work will likewise improve care and physician work life. Laborists would provide in-hospital labor and delivery care, whereas office-based clinicians would manage antepartum and postpartum care.

In a variation of this model, the clinician who manages antepartum care is offered the opportunity to come to the hospital just before the birth to continue to participate in the care of his or her patient.4 In another model, the differentiation between laborist and office-practice clinician might be more definitive,4,5 with the laborist responsible for most deliveries.

The laborist model has the potential to improve care by ensuring that a responsible obstetrician is available to respond to emergencies on labor and delivery. In addition, the laborist model would provide the opportunity for office-based clinicians to work only weekday daytime hours—a delineation that addresses the lifestyle needs of many physicians.

Secular changes in the obstetric workforce may make the laborist model an optimal approach to obstetric practice.4 One obstacle, however, may be that many OBs do not want to surrender the professional satisfaction afforded them when they participate in the continuity of their patients’ care—from the first ambulatory visit through labor and birth. Alternatives to the laborist model—in the form of the nocturnalist and the weekendist—may afford some of the similar benefits while preserving the option for clinicians to participate in both ambulatory and labor care.

…the nocturnalist…

One alternative to dividing obstetric work into what laborists and office-based clinicians each would do is to support the participation of all OBs in both office practice and labor and delivery management while markedly reducing night call for OBs. This modification involves employing a second team of clinicians to handle nighttime labor call—so-called nocturnalists.

Nocturnalists would have the same role as laborists but their responsibility would be limited to nighttime labor call. Management of daytime labor and delivery would still be the responsibility of the OBs who provide ambulatory care for their patients. Nocturnalists would not be responsible for providing ambulatory care for the patients whose care they cover. Because obstetric night call is among the least satisfying part of ObGyn practice,6 development of a nocturnalist model holds the possibility of markedly improving work-life satisfaction.

…and the weekendist

A variation on the nocturnalist model is to hire OBs to cover weekend labor call. In this model, the practicing OB provides all ambulatory care, most of which occurs Monday through Friday, and covers labor and delivery, day and night, during the work week. Weekendists would provide labor and delivery coverage on Saturdays and Sundays and on Mondays that are a holiday. Many practicing OBs would likely be attracted to this model because it guarantees two, sometimes three, days a week for them to spend with their family and friends and to pursue extramedical interests.

Lifestyle and the ObGyn

Many surveys reveal that a key factor influencing the choice of specialty among medical students is how they perceive a specialty’s accompanying lifestyle.7 Today, the work life of an ObGyn is dominated by on-call obligations that typically extend for 24 consecutive hours, followed by an ambulatory office session.8 ObGyns are being challenged to evolve the specialty by reducing the reliance on extended work shifts. We need to develop, implement, and evaluate multiple models by which we can reduce night and weekend obstetric call—and three promising such models are the laborist, the nocturnalist, and the weekendist.

References

1. American Medical Association. Physician socioeconomic statistics. Chicago, IL: Center for Health Policy Research; 2003.

2. Promecene PA, Schneider KM, Monga M. Work hours for practicing obstetrician—gynecologists: the reality of life after residency. Am J Obstet Gynecol. 2003;189:631-633.

3. Wachter RM, Goldman L. The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514-517.

4. Weinstein L. The laborist: a new focus of practice for the obstetrician. Am J Obstet Gynecol. 2003;188:310-312.

5. Frigoletto FD, Greene MF. Is there a sea change ahead for obstetrics and gynecology? Obstet Gynecol. 2002;100:1342-1343.

6. Bettes BA, Chalas E, Coleman VH, Schulkin J. Heavier workload, less personal control: impact of delivery on obstetrician—gynecologists’ career satisfaction. Am J Obstet Gynecol. 2004;190:851-857.

7. Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choices by US medical students. JAMA. 2003;290:1173-1178.

8. Schauberger CW, Gribble RK, Rooney BL. On call: a survey of Wisconsin obstetric groups. Am J Obstet Gynecol. 2007;196:39.e1-39.e4.

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