Stork tries a new strategy

On the morning of her Caesarean section, Tyriesha Tucker met the woman who would deliver her baby - obstetrician Hyun-Joo Lee - for the first time.

That was fine with Tucker, a tiny woman who was 41 weeks pregnant with her second child. She didn't care whether she had a long relationship with the doctor who would cut into her womb that day. What mattered, she said, was that her doctor knew what she was doing.

By early afternoon, Lee, whose job was to care for all the women in labor on Albert Einstein Medical Center's busy maternity floor that day and night, was furiously scrubbing her hands and arms for Tucker's surgery. Within 15 minutes, she was smiling at Tucker's daughter, Sabriah, who yelled and kicked while inhaling her first breaths of cold operating-room air.

"Hi, cutie," Lee said brightly. "Happy birthday."

Not that long ago, most women expected a doctor who saw them through their pregnancy to deliver their baby, no matter when their labor pains began. Sacrificing nights, weekends and family plans was just part of being an obstetrician.

Now, societal changes, from young doctors who demand more family time to heightened concern about safety and efficiency, are leading doctors and hospitals to rethink the division of labor in obstetrics.

Though their numbers are still tiny, hospital-based doctors like Lee - whom Einstein calls "laborists" - are more likely to deliver babies while other obstetricians work uninterrupted in the office or O.R., even enjoy their time off without fear of the pager. Proponents say such specialization improves care and makes it easier to recruit young doctors, who find the field's long hours and high costs of malpractice insurance unappealing.

"This has a predictability to it that is attractive to young people who are going into obstetrics," said Arnold Cohen, Einstein's chairman of obstetrics. "This is a chance to get the top people back into ob-gyn."

The field is evolving. Obstetrics leaders disagree about what exactly a laborist is. Purists say they need to work full time on the labor unit.

Einstein's ob-gyns work exclusively at the hospital about three days a month. On those days, they are responsible for all the women in labor, though other doctors may step in to help. In the past, Cohen said, there might have been more doctors at the hospital because more than one group practice had a doctor on call. Efficiency became more important as other hospitals closed their maternity wards, funneling more pregnant women to Einstein. Births grew from 2,000 five years ago to an expected 3,100 this year.

"With the same [total] number of doctors, we're able to care for more patients because it's much more efficient," Cohen said. Teaching hospitals like Einstein must have obstetricians in the house at all times to supervise residents, but, before the laborist system started in 2004, they worked only with patients who did not have a private doctor.

Patients almost never complain about meeting a new doctor on delivery day, doctors who espouse the laborist model say. In fact, as the size of ob-gyn groups has increased, the odds of knowing the doctor who's on call when your baby decides to emerge have diminished anyway.

On the downside for physicians, the delivery is the part of obstetrical care best reimbursed by insurance companies and it's emotionally rewarding. Some doctors do not want to give it up.

In general medicine, the number of hospitalists - doctors who care only for hospitalized patients - has rocketed from fewer than 500 in 1996 to an estimated 20,000 now, according to the Philadelphia-based Society of Hospital Medicine. Many area hospitals now employ them.

In 2003, Louis Weinstein, chairman of obstetrics at Thomas Jefferson University Hospital, proposed a similar kind of specialization for obstetricians. He said he thought it was a bad idea for doctors who have been up all night delivering babies to be doing surgery the next day. And, because deliveries can turn sour in an instant, he said it was safer to have doctors on the labor unit at all times rather than wait for obstetricians to drive in from their homes or offices.

Then there are the new doctors, many of whom have working spouses and want more control over their hours. "I'm having more and more problems with the Generation X and Y doctors not wanting to take call anymore," he said.

Weinstein, who consults on the subject, said the number of hospitals asking him about laborists had grown dramatically in the last 18 months. "Eventually it's going to come, in my opinion, to most places," he said.

He coined the term "laborist" and has strong feelings about what it means. To Weinstein, laborists are doctors who work full time in the hospital, do only labor and delivery, and work shifts of no more than 12 hours. Community doctors can still come in to catch the baby. He knows of only about 15 hospitals around the country that meet his definition. His own hospital does not have laborists.

Cohen said he thought Einstein's approach, which allows doctors to continue doing prenatal care and form stronger relationships with patients, was better. He calls his doctors laborists, too. "Anybody who covers the labor floor and that's their only responsibility is a laborist," he said. "I am convinced that we have improved the quality of care . . . with this model, whatever you call it."

Shawnee Mission Medical Center near Kansas City calls its labor and delivery specialists "OB hospitalists." In New Mexico, Albuquerque's Presbyterian Hospital has BOBs, for backup OBs.

In this area, Abington Memorial Hospital, where ob-gyn Amy Mackey works full time overseeing labor and delivery, comes closest to Weinstein's original concept. Mackey supervises residents, helps out on C-sections, and delivers babies for doctors who are otherwise occupied. She is also in charge of patient safety on the unit, where about 5,500 babies will be born this year.

Mackey said she missed getting to know patients better, but enjoyed focusing on improving her unit. Community doctors, who are more "guests" on the floor, feel "less ownership of how things are run," she said.

John Kelly, Abington's chief medical officer, said doctors from the hospital's obstetrical groups also rotated through duty on the labor floor, so there are often several OBs present at once. His goal is to make sure that no one doctor is caring for too many women in labor. "Having redundancy is safe," he said.

Mackey's position costs the hospital more money, Kelly said, but, in the long run, a safer unit could be a cheaper one. "If Dr. Mackey's presence prevents one significant adverse outcome, it might pay for 20 years of Dr. Mackey," he said.

Hospital of the University of Pennsylvania has been thinking about hiring laborists, said Thomas Bader, division chief of obstetrics and gynecology. But he is concerned about finding doctors who would be willing to narrow their responsibilities for the long term. "I'm not sure that, as a specialty, we're ready for it," he said.

He is now considering a hybrid system that would put some doctors in charge of all deliveries, but would also let them have broader duties during part of their workweek.

Einstein's Lee, who has three children and a physician husband, said she much preferred doing occasional laborist shifts to being on call seven or eight times a month. She and her husband used to take two cars to church. "You never know when you'll get called in," she said.

Now, she said, "when we're home, we're home. We don't get paged. For me, this has been wonderful."

As much as she likes the arrangement, she would not want to give up her office practice entirely. She likes to get to know patients.

With a resident's help, Lee did three Caesarean sections and presided over the births of five more babies, including a set of twins, on the day of Sabriah's birth.

Like Tucker, 20-year-old Adrienne Baione expected that Lee, a stranger to her, would deliver her son that day. That did not bother her. But that afternoon, just as Baione was getting serious about pushing, her regular obstetrician, Janet Ko, came to the labor floor. She had done a C-section and was finished operating for the day.

A relatively new doctor who is single and childless, Ko tried to deliver her own patients' babies last year. "I found I was here four days in a row without going home," she said. Now she is "stepping back," but still likes to do the deliveries when she can.

She jumped in to help Baione while Lee happily did some paperwork. Once the baby, John Aiden Ludwig, had arrived, Baione said she had been thrilled to hear Ko would be with her: "I said, 'Oh my God. Thank you. Somebody I actually know.' "

View a photo slide show of obstetricians working on the maternity ward at Albert Einstein Medical Center at http://go.philly. com/laboristEndText