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Kathryn Mills, MTMC Laborist

Ask most obstetricians/gynecologists why they chose the specialty, and they'll tell you that it's the rush of helping usher new life into the world.

Yet ask them about the drawbacks, and scheduling will be high on the list. When the baby decides it's time, it's time to catch the baby.

That's one reason why some ob/gyns are choosing to become laborists, obstetricians who work for a hospital or hospital system and cover shifts. Their job is to deliver babies and handle obstetrics emergencies during their shift — and then go home.

One of the first laborist programs in Tennessee was launched Nov. 1, 2006, at Middle Tennessee Medical Center (MTMC) in Murfreesboro, and "it's been a great program so far," said Dr. Charles Brent Boles, MTMC's laborist program medical director.

Laborist programs are modeled after hospitalist programs, which have over the last decade become rather mainstream. Hospitalists, usually general practitioners or internal medicine specialists, work shifts and handle the inpatient population, particularly those patients who don't have a standing physician relationship. In some communities, the relationship between hospitalists and other physicians is so strong that doctors "hand over" their hospitalized patients to the hospitalists, thus freeing themselves to tend only to their office patients and make occasional visits to their hospitalized patients when they deem it's necessary.

Laborists work in much the same way as hospitalists, providing in-house obstetrical care. In the case of MTMC, laborists deliver the babies of women who simply show up at the emergency department in labor; they have had no prenatal care, or they don't have insurance and aren't eligible for TennCare. Hospitalists also handle the deliveries of health department patients and women who happen to be visiting or passing through the community when labor commences or they have an obstetrical problem.

Dr. Kathryn Mills is one of MTMC's three full-time laborists. She left the Tennessee Department of Health to join the new laborist program and particularly enjoys working with the health department patients, who receive the services of a liaison to help schedule and anticipate their hospital interactions. After completing her residency in 2003, Mills worked in private practice but "didn't care for it that much." She said, "I liked the concept of being located in-house, taking care of the indigent population and patients who don't have their own doctors. And I like the lifestyle, as far as being able to leave the hospital and not take work home with you." She estimated that she delivers five babies per week, sometimes as many as 10 weekly.

MTMC delivers more than 2,500 babies each year, and more than 30 each month are health department patients. The three full-time laborists cover seven to 10 12-hour shifts in a two-week period, and the remaining shifts are handled by six ob/gyns, dubbed "moonlighters," who are paid by the hospital per shift. Boles is one of the moonlighters.

Before the laborist program, between 12 and 15 doctors handled MTMC deliveries, participating in a call-sharing arrangement with each physician taking a month in the rotation. "What was very, very difficult about that was, when it was your turn to be on call, you were essentially managing two practices. You really had a double workload," Boles explained. Patients were still scheduled for routine visits, yet the doctors could be called to the hospital unexpectedly — and that call would be the priority. "So, the workload was very demanding, and the disruption to your private practice and to your home life was very intrusive as well," he said.

Thus, last year, Murfreesboro OB/GYNs communicated an "urgent need" to the hospital to change the arrangement, Boles recalled. Boles opened his practice in Murfreesboro in 2005 and brought with him years of experience with a northern Kentucky laborist strategy. That's why he spearheaded the design of MTMC's initiative. "The program here is not a duplicate of that program, but we used a lot of the experience I had there in our ideas and discussions to make progress here getting this program up and running," he said. Laborist programs are so new that there aren't any nationally recognized templates to follow. "It's just up to each individual hospital or healthcare system that wants to establish a program to set it up in the way that best suits individual needs," he said.

Now that MTMC's program has six months under its belt, Boles said there's nothing he would change. While some accounting issues were tweaked early on, he said, the program has operated without interruption since Nov. 1 at 7 a.m.

"From the hospital's standpoint and for the private-practice doctors, there's enhanced patient safety and a greater sense of confidence," he said. "Now we can focus on the patients who come to see us, and we're not having to balance the needs of our practice with essentially another practice of patients we've probably never seen before and probably will never see again. Secondly, we have the added peace of knowing that if one of our patients walks through the doors and there's a true emergency, … the person who's in the building can go ahead and get the care for our patient initiated while we're on the way."

Boles predicted that more and more larger hospitals will implement laborist programs; in fact, MTMC's sister hospital, Baptist Hospital in Nashville, is in the early stages of developing a program modeled on MTMC's success. Furthermore, Boles said he's willing to share his model with others. "I spent 30 minutes on the phone with a gentleman who's an obstetrician in Memphis several weeks ago. He had heard about our program, and he called. He's trying to get his hospital to set up something similar," he said.


May 2007

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