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The birth of a notion (MS)

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Hospitals turning to laborists to deliver babies By Liz Kowalczyk Globe Staff / February 22, 2009

Erin Hawe’s contractions were five minutes apart when she called Cape Cod Hospital at 11 o’clock on a recent Friday night, wondering whether it was time to head in to deliver her second child.

A doctor called her right back, but it wasn’t her longtime obstetrician-gynecologist. It was a total stranger – Dr. Luisa Kontoules, one of a new breed of hospital-based physicians who deliver babies for other doctors’ patients.

Hawe, a 23-year-old from Dennis, was surprised that Kontoules would be delivering her infant, but immediately relaxed after meeting her at the hospital. Kontoules later sat in Hawe’s room answering questions for nearly a half-hour before Hawe was discharged.

"I have never spent that much time with any doctor," Hawe said.

Called laborists or OB hospitalists, specialists such as Kontoules are helping fill a void created by the growing number of obstetrician-gynecologists who have stopped delivering babies because of grueling on-call schedules and high malpractice insurance costs. The Boston-based ProMutual Group, the largest malpractice insurer in the state, said about 65 of the 120 obstetrician-gynecologists it insures have quit delivering babies.

For expectant mothers, who traditionally have carefully hand-picked their obstetricians to see them through pregnancy and delivery, the advent of laborists means they typically won’t meet the doctor attending the birth until they arrive at the hospital.

But some physicians believe the practice will be safer, because laborists can begin caring for pregnant women as soon as they arrive at the hospital. Laborists also work defined shifts, so they generally don’t suffer chronic sleep deprivation from repeated on-call shifts. That could lead to fewer mistakes, though there are no data yet.

Nobody tracks how many laborists are employed in hospitals in Massachusetts or nationwide,but the number is clearly rising, particularly in community hospitals. Ob Hospitalist Group, a company based in South Carolina, said it has placed 60 doctors as laborists across the country and is looking for jobs for another 340 physicians interested in being laborists.

The new specialty is part of what some doctors said is an unavoidable shift in medicine: Fewer doctors have time to care for their patients when they are in the hospital.

Many primary care doctors – who must squeeze more and more patient appointments into the day to make ends meet – infrequently set foot in the hospital; a growing cadre of hospitalists now care for these patients during hospital stays. In other specialties, like obstetrics, surgery, and orthopedics, physicians no longer want to be on call for emergencies because of the disruption to their practices and personal lives.

Dr. Jim Butterick, chief medical officer of Cape Cod Hospital, said the Hyannis hospital decided to hire Kontoules after four of the hospital’s eight obstetrician-gynecologists stopped delivering babies, and those remaining "were getting pulled out of their offices and out of the OR all the time."

Kontoules had worked in private practice in Peabody, but when eight obstetrician-gynecologists on Boston’s North Shore gave up delivering babies over a two-year period, she had no one to help cover her laboringpatients on nights and weekends. For a year, she saw patients in her officeall day Monday through Friday and answered pages at all hours to deliver 300 babies and tend to emergencies at two nearby hospitals.

Exhausted and burned-out, she, too, gave up delivering babies in October 2007. "I physically could not keep up a private practice," said Kontoules, 50.

But she missed ushering tiny infants into the world and last August she took the job at Cape Cod Hospital, where she works every other weekend, from Friday night to Monday morning, so the hospital’s four remaining obstetricians can have a break.

Being a laborist has "returned the joy" to delivering babies, Kontoules said, though she worried, at first, about how expectant mothers would react.

"I knew what it was like in private practice and how much patients bond to their obstetricians," she said. "I have not had a single woman say, ‘I don’t want you, I don’t know who you are.’ They want to feel cared for and have a safe birth and that might overwhelm any disappointment they have."

Besides, she said, many pregnant women are prepared for the possibility that another obstetrician in their doctor’s practice might deliver their babies – although often women have met those doctors.

Another Massachusetts hospital, Morton Hospital and Medical Center in Taunton, has hired two laborists over the past two years, and Brigham and Women’s Hospital in Boston is considering employing them as well. The hospitals pay laborists $125 to $150 an hour and cover their hefty malpractice insurance premiums.

An obstetrician-gynecologist in Massachusetts generally pays between $75,000 and $100,000 a year for malpractice insurance; that amount drops to between $30,000 and $50,000 when a doctor gives up obstetrics and sees patients only for gynecological problems, said Dr. Angela Aslami, chair of the practice committee for the Massachusetts chapter of the American College of Obstetrics and Gynecology. The group plans to survey the state’s 900 to 1,000 obstetrician-gynecologists to determine how many have stopped, or plan to, in the next two years.

Dr. Louis Weinstein, chair of obstetrics and gynecology at Thomas Jefferson University in Philadelphia, coined the term laborist five years ago, and promoted the practice as a way to provide safer deliveries. He proposed having four laborists working 10- to 14-hour shifts to cover all of a hospital’s deliveries. He believes that employing laborists for entire weekend shifts is dangerous because the doctors may get little rest.

But doctors at community hospitals vigorously disagree, saying the number of deliveries is small enough that they get plenty of sleep. Kontoules said that in between deliveringtwo to eight babies per weekend shift and seeing emergency room patients with gynecological problems, she always gets "plenty of sleep."

Overall, said Dr. Robert Barbieri, chair of obstetrics and gynecology at the Brigham, having doctors in the hospital 24 hours a day is a safety improvement, and at smaller hospitals, a weekend-long shift is generally not dangerous. The Brigham, which like most teaching hospitals has obstetricians and physicians in training on-site at all times, is considering hiring laborists for 12-hour weekend shifts to relieve off-site obstetricians of call duty during busy periods.

Dr. Kirti Patel, an OB hospitalist at Morton Hospital who works every other weekend, gave up her traditional practice two years ago because she felt her family life was suffering. Now, the 36-year-old is home with her two young children during the week; her husband cares for them when she’s working.

Patel – who in addition to delivering one or two babies a day, manages post-operative gynecology patients and provides consultations in the ER – said she feels it’s safer for patients because she’s less distracted and less exhausted. "I’m really there for just that patient," she said.

Liz Kowalczyk can be reached at