The Obstetrician Shortage: It Ain't Just Malpractice Suits

[Ralph]

From The New York Times:


August 9, 2005
Wanted: Workaholics to Become Obstetricians
By ALEXANDER FRIEDMAN, M.D.

I knew immediately that I wanted to be an obstetrician-gynecologist.

As a medical student on my second night on call in labor and delivery, I pestered the attending doctors to let me deliver a baby, and six hours later I got my chance. With the guidance of a senior doctor, a plump, slippery, wriggling baby appeared in my hands. My adrenaline ran so fast that my hands shook when I clamped and cut the cord. I passed the infant to the pediatricians and was hooked.

A year and a half later, I sat down to fill out an online residency application. I expected stiff competition. Who wouldn't want the experience of bringing new life into this world, I thought.

I was wrong. Obstetrics-gynecology is quietly reeling from a crisis: not the hot, loud, nasty one involving politicians, lawyers and lawsuits but an insidious one of students voting with their feet.

In the last decade, the number of students entering the specialty has plummeted. In 1996 and 1997, applicants for obstetrics and gynecology residencies were lined up around the block. Since then, the number of applicants has gone into free fall. Only 743 graduating medical students in the United States applied for 1,142 residency slots in 2004. More than a third of the slots went to foreign medical graduates or remained empty.

Men in particular shy away from the specialty. In 1999, more than 40 percent of graduating residents were men. This year, men make up only 10 to 15 percent of the applicants. During my residency interview at Columbia, Dr. Richard Berkowitz, a prominent high-risk obstetrician, assessed the extent of the crisis. "I've been through the best of times and the worst of times," he said. "This is the worst of times."

Oddly, as an ambitious medical student I benefited from this. I applied to 26 residency programs, most affiliated with famous hospitals and prestigious universities. I expected to get interviews at about half, with serious interest from a couple of places.

But soon after my demographic information went online, interview requests flooded my in-box.

Every program I applied to offered me an interview, many even before they saw objective criteria like my grades and board scores.

I was elated that so many programs showed an interest in me, but at the same time, a gnawing ambivalence set in. Crisscrossing the country and interviewing at different programs, I asked residents, professors and department heads why the specialty had fallen on such hard times. "Lifestyle" was the predominant response.

More than any time in the past, medical students want careers with predictable schedules.

They want to go to their children's soccer games, read for pleasure and not be called in to the hospital at night.

Specialties like dermatology, radiology and anesthesiology offer flexibility. Obstetrics and gynecology does not, and students are turning away from the most demanding specialties in unprecedented numbers.

Obstetrics is consuming and unpredictable. The hours are long and caring for sick patients can blot out all other priorities. The stakes are high: very often you are caring for two patients and not one, and bad outcomes can be catastrophic for a family.

When you do go home, you worry, sleep uneasily and wake up early the next morning. Yet the payoff is always there: you help patients and bring life into the world.

I experienced the ups and downs of the specialty last fall when I spent a month at Brigham and Women's Hospital in Boston, taking care of women whose pregnancies had serious complications. The long hours took a toll on my personal life. I spent most of my time outside of the hospital sleeping, I gained weight and I had no time for relationships. My grandmother became ill and I was not able to visit her because of clinical responsibilities.

During that month, I flirted with the idea of choosing another specialty. Ultimately, I enjoyed the work too much.

Women deserve the best doctors. If this trend keeps up they will not get them. Society needs good dermatologists and radiologists, well-rested doctors to look at our skin and to read X-rays. It also needs workaholics, doctors so invested in their patients that it occasionally becomes unhealthy.

After my training is finished, I hope I will regularly get to my children's soccer games.

But if I miss a few, that is O.K., too.

[Corlyss_D]

Interesting article, Ralph. Thanks for putting it up. I thought that God had invented Caesarians for ob-gyns who wanted regular schedules. At any rate, I heard about 1999 that ob-gyns frequently came from the bottom 1/3rd of the graduating class. Shocking. Maybe that's one of the reasons why insurance rates are so high. I seem to recall in my latter days in law school that the malpractice insurance lobby went to Mississippi or West Virginia which didn't have a requirement to pass a bar exam in order to practice law, and told 'em if they didn't begin requiring a bar exam, they were going to quit underwriting the attys in the state. Maybe they need to find a similar leverage over the ob-gyn docs.

[Ralph]

Interesting article, Ralph. Thanks for putting it up. I thought that God had invented Caesarians for ob-gyns who wanted regular schedules. At any rate, I heard about 1999 that ob-gyns frequently came from the bottom 1/3rd of the graduating class. Shocking. Maybe that's one of the reasons why insurance rates are so high. I seem to recall in my latter days in law school that the malpractice insurance lobby went to Mississippi or West Virginia which didn't have a requirement to pass a bar exam in order to practice law, and told 'em if they didn't begin requiring a bar exam, they were going to quit underwriting the attys in the state. Maybe they need to find a similar leverage over the ob-gyn docs.

*****

There is no state that in your lifetime didn't require a bar exam. Before the MBE state exams varied enormously.

There's a recurrent issue about unnecessary Caesarians. Teddy was born that way and the attending OB/GYN made the right call. But it was convenient to know exactly when to be at New York Hospital.

[Corlyss_D]

There is no state that in your lifetime didn't require a bar exam.

All I know is what the Bar Counsel told us.

But it was convenient to know exactly when to be at New York Hospital.

[Ralph]

Incidentally, Wisconsin is the only state that doesn't require a bar exam for graduates of the state's two law schools, U. of Wisconsin and Marquette.

[Teresa B]

Hi All,

Interesting post, Ralph. This young doctor is still in the idealistic phase, and obviously enjoys his work. I give him kudos for that, and I hope he continues to deliver (in every way) enthusiastic and excellent care to his patients.

As one of those "well-rested" dermatologists who "look at our skin," I easily picked up his nascent bias against those of us who chose one of the specialties he considers less respectable. (I hope he never gets melanoma, or he may end up thanking one of us skin-lookers for saving his life.)

At any rate, the prime reason I didn't choose OB/GYN (despite the thrill of delivering a baby, which was cool) was that in 1977, the field was still dominated by men, and although there were exceptions, the residents and faculty in OB/GYN at USF Med school were the most arrogant a--holes this side of the Milky Way.

One of the residents called me in to examine a patient because he needed a "pair of ovaries" in the room. (I suppose those of the patient didn't count.) That was only one of endless insults and nasty jokes that we women students were subjected to. (Dont' even get me started on the insults the residents tossed around behind the backs of their 14 and 15-year-old pregnant patients.)

A bad, bad experience, which did not happen in any other specialty I rotated through in school. But enough to sour me on that field for good.

All the best, Teresa

[Ralph]

I think dermatologists are great people!!!!!!

[jbuck919]

I've had more dermatological problems than you could shake a stick at: seborrhea, acne persisting to my present age (50), basal cell tumor, removal of various lesser things. These all sound minor, but if it weren't for modern dermatology and the magic bullet of, say, tetracycline, I couldn't function as a teacher (or in most professions) simply on the basis of presentation. Hooray for dermatologists!

[Corlyss_D]

Incidentally, Wisconsin is the only state that doesn't require a bar exam for graduates of the state's two law schools, U. of Wisconsin and Marquette.

I believe that was the arrangement for Mississippi as well. I think West By-God didn't have a law school, but that seems unlikely.

[Corlyss_D]

I easily picked up his nascent bias against those of us who chose one of the specialties he considers less respectable.

Maybe it's like the Marines, who think the rest of the Armed Services are also-rans when it comes to combat arms. The ob-gyn field sounds like the most demanding in terms of inability to plan certainly on anything.

Anyone here ever see the show Everwood? The show's premise in the first two years was what happens to a neurosurgeon who was so good he never let his family get between him and a patient. The end result was that when his wife, the emotional glue of the family, was killed in a car wreck on the way to their gifted pianist son's recital, while the doc had to decline to go because "his patient needed him," the family was almost destroyed by the grief and resentment. At one point, the enraged son says to the father "I wish it had been you killed instead of Mom!" The dad's solution to this thorny dilemma of his neglect and the loss of his wife was to move the family to the fictitious Everwood, Colorado, (actually filmed here in Ogden) and attempt to reconnect with his two children.

So here's what I'd like to know from Teresa: is it common in other medical disciplines for the practictioners to use the patients as an excuse to avoid their families? I mean ob-gyns can almost count on no personal life judging by this young man's description. How about others?

[Ralph]

Corlyss,

I'm sure Teresa will provide her view but I have mine. My law school averages 2-5 entering students each year who are M.D.s. Rarely is one young. Most have between 20-25 years of practice in many specialties.

We just graduated an OB/GYN who had a solo practice for nearly 25 years. He told me that he never took a vacation longer than a week or ten days and even that about once a year. On the other hand my current, very experienced opthalmologist who shares an Upper East Side office with his endocrinologist wife enjoys a leisurely CT country lifestyle - but without much travel. And few emergencies-he has a Manhattan-based colleague cover most of them.

The doctors I've taught with the most free time are anesthesiologists. The mother of a favorite former student who is now, with her husband, close friends was chief of anesthiology residency at Columbia-Presbyterian for years. She worked very set hours and she took that specialty abandoning a surgical residency she loved when she became pregnant the second time.

A top dentist, at the time, doesn't currently find practice of either dentistry or law too distracting or time-consuming. He's in a federal penitentiary for money laundering.

I currently have a student whose mom, a pediatric oncologist, was my student over twenty years ago. She worked strictly in hospitals and had a regular schedule. But her practice must have been draining emotionally.

My kid's pediatrician managed to go to law school at night for four years while in a then two-M.D. practice and it took enormous stamina to deal with both lives. He didn't see much of his family during that time.

I have more stories but I need a swim.

[Teresa B]

Hi Guys,

First off, thanks, Ralph and jbuck--I feel better!

As for your question, Corlyss--I don't doubt there may be some physicians who use their overly busy practice to avoid family responsibilites. I don't know, but most doctor friends of mine don't seem to do that, at least consciously. Some are truly dedicated, some are just workaholics or money-motivated, some are stuck in specialties with horrible hours and are burnt out.

I did 3 years of internal medicine residency before I did derm, so I paid my dues with the long hours. At that time, I was unmarried, no kids. So the "family I never saw" was my cat (who did suffer, I'm convinced of it, as it was very skittish and neurotic). But I was lucky to get into a derm residency where I could work maybe 55 hours a week instead of 100 (And thus incur the taunting of general surgery residents who took joy in screaming "What, a dermatologist in the hospital after 4 PM??" and such. But they were just jealous.)

At this point, I work the hours I want and dump stuff I don't want on my junior partner. Works for me.

All the best, Teresa

[Ralph]

And high power lawyers in major firms are expected, depending on the city, to bill these days between 2200 and 2500 hours annually. And billable hours do not include bar association service, law firm management duties and so on.

Seven-day weeks are common. So is divorce and shock when kids get into serious trouble with their schools and not infrequently the police.

Wall Street bankers and brokers are the same.

Do these "Masters of the Universe" (to borrow from Tom Wolfe) seek absence from home and family? Some do but for most it's power and money and for the Alpha Males, there's always a stunning, sexy Trophy Wife to catch when taking a break and recognizing that the sweetheart from high school or college has aged.