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Changing practice: ob.gyns. share how new technologies, specialization, and regulations have reshaped the field over 50 years.

As a practicing obstetrician-gynecologist for nearly 40 years, Leonard Brabson, MD, has watched his specialty transform in ways both large and small.

For starters, his regular work attire in 1977--a shirt and tie--is now scrubs. The paper charts that once filled his office shelves have been replaced with electronic records. And the cumbersome machines that once took blurry, still pictures of a fetus have advanced by leaps and bounds and become a staple of prenatal care.

The range of clinical responsibilities that ob.gyns. undertake has also evolved, Dr. Brabson said.

"Back then, we were expected to be generalists. If [a patient] had a cancer, you took care of it. If [she] had a fertility problem or problem with endocrinology, you took care of it. Of course, now if I have a female cancer, we refer them to the gyn-oncologist. But when you go back 40 years and beyond, we did mostly everything."

The practice of obstetrics and gynecology has experienced myriad changes over the last 5 decades, from new technology to increased regulations to higher insurance premiums.

The ob.gyns. of today are practicing in a vastly different environment than their predecessors, and while many of the differences have improved patient care and enhanced efficiency, physicians also note that some changes have harmed the doctor-patient relationship and created career dissatisfaction.

"Certainly, the advances of modern medicine have enabled the current physician to provide the patient a level of care unparalleled in history," said Charles E. Miller, MD, a reproductive endocrinologist and minimally invasive gynecologic surgeon in private practice in Naperville and Schaumburg, 111. "However, I do think medicine has lost some of its professionalism. All too often, physicians are so interested in lifestyle that they are willing to practice by way of shift work and thus, not willing to provide true responsibility for their patients. Furthermore, I am concerned that the bottom line has taken over the practice of medicine."

More volume, less time

Most long-time physicians agree that higher patient volumes and increasing administrative burdens have diminished the time they are able to spend with patients.

"Relationships back then were much closer because we had time," said Ronald J. Pion, MD, an ob.gyn. for nearly 50 years and a clinical professor at the University of California, Los Angeles. "We weren't seeing 30 people at a morning visit."

Rising clinical documentation and coding are the top administrative tasks taking away from one-on-one patient care, said Kristen Zeligs, MD, chair of the American Congress of Obstetricians and Gynecologists' Junior Fellow Congress Advisory Council and a gynecologic oncology fellow at Walter Reed National Military Medical Center in Bethesda, Md.

"The volume of administrative tasks is steadily increasing," she said. "It sometimes takes twice as long to document a patient's visit in comparison to the visit itself."

But there are other factors straining the doctor-patient relationship. Decades ago, first-time mothers often stayed with one doctor for a lifetime, Dr. Brabson recalled, having all of her babies delivered by a single ob.gyn. The same can't be said for today, where insurance changes, job relocations, and a lack of connections often lead patients to switch physicians frequently.

"Now a lot of patients [move on] from one year to the next," Dr. Brabson said. "There's not that same loyalty."

Doctors, too, traditionally stuck with patients over the long haul, he added. In the past, if an ob.gyn treated a patient during pregnancy, that same physician was present during the delivery, even if it meant leaving a vacation early or coming in on a night off.

"Now the younger docs, especially those that have families with small children, when it's not their night on call and it's 5 o'clock, they're checking out," Dr. Brabson said. "One of my partners right now, she started inducing someone yesterday. Well today's her day off, so I'm going to do the delivery. That's been a big change."

Highs and lows of liability premiums

Another pressure on the specialty over the last couple of decades has been the high cost of liability insurance.

In 1987, while in private practice, Owen Montgomery, MD, paid $25,000 for his annual medical liability coverage. By 2003, his employer, Drexel University, was footing a $160,000 insurance bill for each of its ob.gyns. Dr. Montgomery, who is now chair of obstetrics and gynecology at Drexel University in Philadelphia, said his institution is now self-insured since it was too costly to pay for commercial insurance for all its physicians.

"2003 was really the peak of the liability crisis," Dr. Montgomery said. "Hospitals were closing. Doctors were giving up practice. It's a little better now than it was."

While ob.gyns. still pay higher premiums than many other specialties, the legal climate has improved in recent years, said Paul Greve Jr., executive vice president and senior consultant for the Willis Healthcare Practice, and author of the 2016 Medical Liability Monitor, an annual report that surveys medical liability premiums.

"The best way to characterize the overall environment for medical professional liability is stable," he said. "In the area of obstetrics, for the first time ever in recent years, we are seeing lower frequency and lower severity [of lawsuits]."

The lower number of filings is largely due to patient safety initiatives among ob.gyn. programs and tort reforms--many of which have been upheld by courts in the last decade, Mr. Greve said.

Of course, the rate of premiums greatly differs depending on location, with ob.gyns. in Eastern New York paying a high of $214,999 and ob.gyns. in Minnesota paying a low of $16,449 in 2016, according to the Medical Liability Monitor.

"The environment is specific to the region," Mr. Greve said. "New York City is still very problematic. Chicago is still very problematic. There are some pockets around the country where there's no damage caps, and it's really tough to defend claims."

Technology ups and downs

Another fairly new pressure on ob.gyns. is the integration of the electronic health record and the federal reporting requirements that go along with it.

"Most practicing ob.gyns. are really fed up with the computerization of medicine and the tasking and the charting," Dr. Montgomery said. "For every hour you spend seeing patients, you spend 1 or 2 hours doing computer chart work and paperwork. Most doctors don't go into medicine so they can type; they go into medicine to take care of patients."

The Internet age also poses challenges when it comes to patients conducting their own "research," said Megan Evans, MD, an ob.gyn. at Tufts Medical Center, Boston.

"One con I certainly struggle with is the speed of information at patients' fingertips," she said. "A research article might be picked up by the media before it's published and instantly [become] headline news or on blogs and social media. Not only do you have to be up to date with the latest research and recommendations, but you also have to navigate the misinformation that may have already circulated."

Protecting the security of patients' medical records in the digital age is another worry, she said.

But for Dr. Evans, who completed her residency training in 2015, having dozens of digital tools at her disposal as she treats patients is definitely an upside to today's practice environment.

"I can review a practice bulletin, look up the latest treatment regimens, and contact my colleagues with a quick question--all on my iPhone," she said. "I also believe there is so much potential for electronic medical records and how they communicate with each other."

Advancements in ultrasound, fetal monitoring, and other medical technologies have also allowed ob.gyns. to intervene earlier and save lives.

Dr. Brabson recalled the helplessness he and other physicians felt in the 1970s when it came to delivering extremely premature babies.

"We didn't really feel like you could save a baby under 2 pounds," he said. "When I was a medical student, if you had a baby under 2 pounds, very commonly what they would do is lay the baby up on the table and watch and see how vigorous it was going to be, and if it really did breathe and carry on for awhile, then you might take it to the nursery. The equipment that we have to save babies with today, compared to 40 years ago, that's a dramatic change."

A changing focus for the future

If current trends continue, Dr. Brabson's early experience of being a generalist ob.gyn. won't be the norm. Instead, more ob.gyns. will choose to subspecialize. Whether this change is positive or negative for the specialty depends on who you ask.

"You could argue the pros and cons for both sides," Dr. Zeligs said. "For me, it takes away from what drew me to the specialty--the breadth that ob.gyn. offers, both as a primary care specialty and as a surgical subspecialty."

However, choosing one focus may offer some doctors a way to capture that elusive professional and personal balance, she added.

Despite the changing landscape of clinical duties and business operations, some parts of ob.gyn. practice have remained intact, according to Dr. Brabson. "The most rewarding and enjoyable part of the job is developing a relationship of mutual trust and respect," he said. "As a result of developing such a relationship, both the patient and the doctor come away with positive feelings. This has not changed."

On Twitter @legal_med

Caption: Dr. Leonard Brabson has been an ob.gyn. for nearly 40 years. He proudly displays a shirt he received from one of his patients.

Caption: DR. MILLER

Caption: DR. PION

Caption: DR. ZELIGS


Caption: DR. EVANS


Please note: Illustration(s) are not available due to copyright restrictions.
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Title Annotation:PRACTICE: Paperwork, shift work increase
Author:Gallegos, Alicia
Publication:OB GYN News
Date:Dec 1, 2016
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