Professional Liability and Other Career Pressures: Impact on Obstetrician-Gynecologists’ Career Satisfaction

Interventions to reduce unnecessary caesarean sections in healthy women and babies

Optimising the use of caesarean section (CS) is of global concern. Underuse leads to maternal and perinatal mortality and morbidity. Conversely, overuse of CS has not shown benefits and can create harm. Worldwide, the frequency of CS continues to increase, and interventions to reduce unnecessary CSs have shown little success. Identifying the underlying factors for the continuing increase in CS use could improve the efficacy of interventions. In this Series paper, we describe the factors for CS use that are associated with women, families, health professionals, and health-care organisations and systems, and we examine behavioural, psychosocial, health system, and financial factors. We also outline the type and effects of interventions to reduce CS use that have been investigated. Clinical interventions, such as external cephalic version for breech delivery at term, vaginal breech delivery in appropriately selected women, and vaginal birth after CS, could reduce the frequency of CS use. Approaches such as labour companionship and midwife-led care have been associated with higher proportions of physiological births, safer outcomes, and lower health-care costs relative to control groups without these interventions, and with positive maternal experiences, in high-income countries. Such approaches need to be assessed in middle-income and low-income countries. Educational interventions for women should be complemented with meaningful dialogue with health professionals and effective emotional support for women and families. Investing in the training of health professionals, eliminating financial incentives for CS use, and reducing fear of litigation is fundamental. Safe, private, welcoming, and adequately resourced facilities are needed. At the country level, effective medical leadership is essential to ensure CS is used only when indicated. We conclude that interventions to reduce overuse must be multicomponent and locally tailored, addressing women's and health professionals' concerns, as well as health system and financial factors.

Amount and quality of sleep: exploring the role of stress and work experience in a sample of obstetrician-gynecologists

INTRODUCTION

Sufficient sleep is necessary for optimal performance and the delivery of safe and effective health care. To establish an empirical understanding of physician fatigue, the present study investigated the factors that contributed to the amount and the quality of sleep among obstetricians and gynecologists (ob-gyns).

METHODS

A survey of personal and work experiences was sent to 495 eligible physicians belonging to the American College of Obstetricians and Gynecologists (ACOG). Data were obtained from 287 ob-gyns for a response rate of 58.0%. Associations between sleep-related items and measures of stress and work-related factors were explored.

RESULTS

Ob-gyns in our sample reported sleeping an average of 6.5 hours a night with 29.2% indicating that they received very or fairly bad quality of sleep. Average amount and quality of sleep were found to be independently related to the hours worked weekly, colleague support for a work-home balance, practice setting, perceived work-control, physician-specific stressors and perceived stress. In summary models, hours worked and perceived stress scores consistently emerged as predictors of amount of sleep.

CONCLUSIONS

Overall, findings explained a small portion of the variance in sleep. Considering the multitude of factors that contribute to sleep, subtle associations warrant further investigation.

Lessons from a decade of technical-scientific opinions in obstetrical litigation

The authors aimed to assess the Portuguese circumstances concerning situations of medico-legal dispute in Obstetrics, evaluate the conclusions of technical-scientific opinions and analyze their consequences. The analysis of all cases of Obstetrics medical responsibility examined in Medico-legal Council since the creation of the National Institute of Legal Medicine was performed. Technical-scientific opinions of those files were examined according to the existence of a causal link and of infringement of the 'leges artis'. The most common reasons for dispute in Obstetrics were perinatal asphyxia (50%), traumatic injuries of the newborn (24%), maternal sequelae (19%) and issues related to prenatal diagnosis and/or obstetric ultrasound (5.4%). In the technical-scientific opinions of files examined, the existence of a causal link was established in 17.4%, and the infringement of the 'leges artis' was suggested in 15.5% of cases, numbers which have grown significantly over the years and which are particularly relevant in the proceedings of perinatal asphyxia and traumatic lesions of the newborn. In 11% of cases the opinion was inconclusive due to the poor quality of the clinical process sent for analysis. These results highlight the impact that litigation can have on the professional activity and personal lives of obstetricians. It should alert them for the need to better fulfill medical clinical files in order to reduce or avoid medico-legal conflicts, as well as to the fact of the increasing practice of defensive medicine and its consequences in daily clinical routine for doctors and patients.

Ethical concerns and career satisfaction in obstetrics and gynecology: a review of recent findings from the Collaborative Ambulatory Research Network

Obstetricians-gynecologists (ob-gyns) are frequently confronted with situations that have ethical implications (e.g., whether to accept gifts or samples from drug companies or disclosing medical errors to patients). Additionally, various factors, including specific job-related tasks, costs, and benefits, may impact ob-gyns' career satisfaction. Ethical concerns and career satisfaction can play a role in the quality of women's health care. This article summarizes the studies published between 2005 and 2009 by the Research Department of the American College of Obstetricians and Gynecologists, which encompass ethical concerns regarding interactions with pharmaceutical representatives and patient safety/medical error reporting, as well as ob-gyn career satisfaction. Additionally, a brief discussion regarding ethical concerns in the ob-gyn field, in general, highlights key topics for the last 30 years. Ethical dilemmas continue to be of concern for ob-gyns. Familiarity with guidelines on appropriate interactions with industry is associated with lower percentages of potentially problematic relationships with pharmaceutical industries. Physicians report that the expense of patient safety initiatives is one of the top barriers for improving patient safety, followed by fear of liability. Overall, respondents reported being satisfied with their careers. However, half of the respondents reported that they were extremely concerned about the impact of professional liability costs on the duration of their careers. Increased familiarity with guidelines may lead to a decreased ob-gyn reliance on pharmaceutical representatives and free samples, whereas specific and practical tools may help them implement patient safety techniques. The easing of malpractice insurance and threat of litigation may enhance career satisfaction among ob-gyns. This article will discuss related findings in recent years.

TARGET AUDIENCE

Obstetricians & Gynecologists and Family Physicians.

LEARNING OBJECTIVES

After the completing the CME activity, physicians should be better able to analyze how interactions with pharmaceutical industry may pose ethical dilemmas, examine current barriers to implementing patient safety initiatives, and evaluate the factors that influence career satisfaction among obstetrician-gynecologists.

A 'no-fault' cerebral palsy pension scheme would benefit all Australians

The Australian Federal Productivity Commission is proposing two new schemes to better support those with major disability. The main National Disability Insurance Scheme (NDIS) will provide long-term care and support for the disabled. A smaller scheme, the National Injury Insurance Scheme (NIIS), will provide 'no-fault 'support for those following an accident or 'medical injury'. It is proposed that cerebral palsy (CP) is part of the NIIS. While this brings quicker and more equitable benefits to CP families, the scheme labels CP as a 'medical accident' and infers preventability. Obstetricians will fund much of the system. Despite being labelled a 'no-fault' system, maternity staff can still be litigated for extensive 'head of damages', eg loss of earning capacity. An additional option is for federal/state legislation to introduce a true 'no-fault' lifetime pension specifically for all children on CP registers. This pension would be graded by degree of disability and dependent on waiving civil litigation. Savings in medico-legal costs and potentially a 7% reduction in caesarean delivery would cover the estimated annual cost of $50 000 per annum indexed life pension for severe CP cases and the total annual cost of AUD $93 million for Australia. This pension and the NDIS would help cover the needs of children with CP without recourse to prolonged litigation and without detriment to the maternity services of Australia, caused by defensive obstetrics and maternity hospital closure because of CP litigation.

Pregnant students in the gross anatomy laboratory: policies and practices at chiropractic colleges

Chiropractic and medical colleges have experienced a significant increase in the number of female applicants in recent years, a percentage of whom are pregnant or become pregnant following admission. It is therefore important to ask the question: How do institutions that educate future health care providers address the issue of pregnancy and the gross anatomy laboratory? A survey instrument was developed and pretested. IRB approval was obtained. The administrators charged with overseeing the policies and practices for the gross anatomy laboratory at each of the 16 chiropractic colleges in the USA were identified and contacted. An email containing a link to the Web based survey was sent to each, using SurveyMonkey. The survey response rate was 100%. A majority of colleges (69%) have a written policy regarding pregnancy and the gross laboratory. Of these, 36% allow pregnant students to take the laboratory if a waiver is signed, 18% do not allow them to take the laboratory, 18% allow them to take it without a waiver, and 27% have other policies. In cases where students do not take the gross laboratory while pregnant, 64% of colleges require them to take the laboratory after completion of their pregnancy, 27% require them to complete an alternative (dry) laboratory, and 9% have other policies. Considerable diversity exists in the way colleges address this issue. It is at present unknown whether pregnant students or their fetuses are at any risk from laboratory chemicals. Risk assessment research is needed before consistent policies can be developed.

Survey of obstetric and gynecologic hospitalists and laborists

OBJECTIVE

The objective of the study was to obtain descriptive information about obstetricians/gynecologists who currently are practicing as hospitalists or laborists.

STUDY DESIGN

A survey was emailed to all actively practicing member Fellows of the American College of Obstetricians and Gynecologists in April 2009. A second emailing of the survey was sent in May 2009.

RESULTS

Obstetrician/gynecologist hospitalists and laborists are significantly younger than the rest of the obstetrician/gynecologist sample by age and years in residency and have a high rate of career satisfaction. There was a great deal of variation in work schedules and compensation of the respondents.

CONCLUSION

We analyzed the rapidly growing hospitalist/laborist model of care within the obstetrician/gynecologist specialty. The laborists and hospitalists model provides an alternative type of practice for obstetricians/gynecologists, and it is associated with high career satisfaction. It is important that we continue to monitor the needs of this burgeoning field of clinical practice.

Physician career satisfaction: examining perspectives of the working environment

The author examined the relationship among factors influencing the career satisfaction of 2,105 physicians. Data from the 2005 Community Tracking Study Physician Survey were used to obtain 5 latent factors. Structural equation modeling was then applied to extract information on factor interrelationships with physician satisfaction. The main results indicate that underinsurance is negatively associated with physician career satisfaction. Thus, spillover effects that are related to decreased physician satisfaction may increase with greater proportions of underinsurance.

The impact of malpractice burden on Michigan obstetrician-gynecologists' career satisfaction

BACKGROUND

Medical services for pregnancy and childbirth are inherently risky and unpredictable. In many states, obstetrician-gynecologists (OB-GYNS) who attend the majority of childbirths in the United States and provide the most clinically complex obstetric procedures are struggling with increasing malpractice insurance premiums and litigation risk. Despite its significant implications for patient care, the potential impact of malpractice burden on OB-GYN physicians' career satisfaction has not been rigorously tested in previous research.

METHODS

Drawing on data from a statewide survey of obstetric providers in Michigan, this paper examined the association between medical liability burden and OB-GYNs' career satisfaction. Malpractice insurance premiums and malpractice claims experience were used as 2 objective measures for medical liability burden. Descriptive statistics were calculated and multivariable logistic regressions estimated for data analysis.

RESULTS

Although most respondents reported satisfaction with their overall career in medicine, 43.7% had become less satisfied over the last 5 years and 34.0% would not recommend obstetrics/gynecology to students seeking career advice. Multivariable regression analysis showed that compared to coverage through an employer, paying > or =$50,000/year for liability insurance premium was associated with lower career satisfaction among OB-GYNs (odds ratio, 0.35; 95% confidence interval, 0.13-0.93). We found no significant impact of malpractice claims experience, including both recent malpractice claims (during the last 5 years [2001--2006]) and earlier malpractice claims (>5 years ago), on overall career satisfaction.

CONCLUSIONS

The findings of this study suggest that high malpractice premiums negatively affect OB-GYN physicians' career satisfaction. The impact of the current medical liability climate on quality of care for pregnant women warrants further investigation.

Outlook for the future of the obstetrician-gynecologist workforce

OBJECTIVE

The objective of the study was to assess the future physician workforce with a sample of obstetrician-gynecologists.

STUDY DESIGN

Two separate surveys regarding career satisfaction and retirement plans were sent to random samples of obstetrician-gynecologists under age 50 years (n = 2,000) and over the age of 50 (n = 2,100).

RESULTS

Obstetrician-gynecologists over the age of 50 years who were working part time or were female were more satisfied than those working full time or were male. Obstetrician-gynecologists (under and over age 50 years) who were concerned about liability and unable to balance their work and personal lives were more dissatisfied. Obstetrician-gynecologists retired earlier than planned because of rising malpractice costs and later than planned because of high career satisfaction.

CONCLUSION

Low career satisfaction may be adding to the already shrinking physician workforce. Offering part-time work opportunities and alleviating liability concerns may increase career satisfaction and help to combat a future of the physician workforce shortage.

Why obstetrics/gynecology, and what if it were not an option? A survey of resident applicants

OBJECTIVE

The purpose of this study was to assess the secondary residency choice of obstetrics/gynecology and family medicine residency applicants and to determine the most and least appealing aspects of each specialty.

STUDY DESIGN

This prospective cohort study surveyed residency applicants in obstetrics/gynecology and family medicine from 2004-2007 at the University of New Mexico (obstetrics/gynecology and family medicine) and the University of California-San Francisco (obstetrics/gynecology). Applicants completed an anonymous 5-question survey about their secondary choice of specialty, least likely residency choice, and the most and least appealing aspects of their chosen specialty.

RESULTS

Forty-six percent obstetrics/gynecology applicants would have chosen a primary care specialty, and 37% would have chosen a surgical specialty. The most appealing aspects of obstetrics/gynecology were surgery and obstetrics. The least appealing aspects were work hours and liability concerns.

CONCLUSION

Obstetrics/gynecology applicants are divided between primary care and surgical specialties as their secondary choice. Core aspects of surgery and obstetrics are most appealing. Emphasis on these components of the specialty in medical school may improve student recruitment into obstetrics/gynecology.

Faculty attrition in obstetrics and gynecology

OBJECTIVE

The purpose of this study was to explore why obstetrician/gynecologists leave academic practice.

STUDY DESIGN

From a sample of 5000 ACOG fellows, we identified obstetrician/gynecologists in faculty positions and those who had left academic practice. These groups were sent a survey to explore aspects of job satisfaction. Relationships between variables were tested using chi2 analyses. Means were computed for each subscale and differences between current and past faculty were tested with a multivariate analysis of variance model.

RESULTS

There was a 65% response rate to the job satisfaction survey for a total of 280 current faculty and 146 previous faculty. There was no difference between the groups in job satisfaction. Faculty rated opportunities for teaching and administration more important as components of job satisfaction. Practitioners who left academics were more likely to be previous junior faculty and generalists.

CONCLUSION

Junior faculty and generalists are more likely to leave academic practice than senior faculty and subspecialists.

Gender Gaps in Income and Productivity of Obstetricians and Gynecologists

OBJECTIVE

To investigate differences in income, productivity, and practice style between male and female obstetrician-gynecologists between 1990 and 2002.

METHODS

The primary data were the Socioeconomic Surveys of Fellows conducted by the American College of Obstetricians and Gynecologists (ACOG). The surveys contained complete responses from 3,698 obstetrician-gynecologists. Linear regression analysis was used to investigate gender differences in income, productivity, and practice style.

RESULTS

Female obstetrician-gynecologists were younger, had been in medical practice fewer years, earned lower annual incomes ($196,000 versus $257,000), and exhibited lower productivity. Even when considering only young obstetrician-gynecologists (40 years old or younger), women earned annual incomes that were 23% lower, worked 10% fewer hours, saw 9% fewer patients, and performed 21% fewer procedures. The raw income gap between male and female obstetrician-gynecologists of all ages fell from 31% in 1990 to 19% in 2002, whereas for young obstetrician-gynecologists it remained stable at approximately 19%. However, despite this apparent stability, the nature of the income gap changed: whereas differences in productivity and practice style explained only half of the income gap in the 1990s, by 2002 these factors explained nearly all of the income gap.

CONCLUSION

Between 1990 and 2002, female obstetrician-gynecologists earned lower annual incomes than male obstetrician-gynecologists, even when matched on age. However, by 2002 this income gap was almost entirely explained by gender differences in productivity and practice patterns.

Job satisfaction among obstetrician-gynecologists: a comparison between private practice physicians and academic physicians

OBJECTIVE

Physician job satisfaction has been the subject of much research. However, no studies have been conducted comparing academic and private practice physician satisfaction in obstetrics and gynecology. This study was undertaken to measure satisfaction levels for academic and private practice obstetrician-gynecologists and compare different aspects of their practice that contributed to their satisfaction.

STUDY DESIGN

A survey was mailed to randomly selected obstetrician-gynecologists in Memphis, TN; Birmingham, AL; Little Rock, AR; and Jackson, MS. Physicians were asked to respond to questions concerning demographics and career satisfaction. They were also asked to assess the contribution of 13 different aspects of their practice in contributing to their job selection and satisfaction using a Likert scale. A score of 1 meant the physician completely disagreed with a statement regarding a factor's contribution or was completely dissatisfied; a score of 5 meant the physician completely agreed with a factor's contribution or was completely satisfied. Simple descriptive statistics, as well as the 2-sample t test, were used. Likert scale values were assumed to be interval measurements.

RESULTS

Of the 297 questionnaires mailed, 129 (43%) physicians responded. Ninety-five (74%) respondents rated their overall satisfaction as 4 or 5. No significant difference was found between academic and private physicians when comparing overall job satisfaction (P = .25). When compared to private practice physicians, the aspects most likely contributing to overall job satisfaction for academic physicians were the ability to teach, conduct research, and practice variety (P = .0001, P = .0001, and P = .007, respectively). When compared with academic physicians, the aspects most likely contributing to job satisfaction for private practice physicians were autonomy, physician-patient relationship, and insurance reimbursement (P = .0058, P = .0001, and P = .0098, respectively). When choosing a practice setting, academic physicians found variety, teaching, and research to be more important (P = .0027, P = .0001, and P = .0001, respectively). In contrast, private practice physicians found autonomy, physician-patient relationship, coworkers, and geographic location to be more important (P = .0005, P = .0001, P = .0035, and P = .0016, respectively).

CONCLUSION

Academic and private practice physicians are equally satisfied with their careers. However, teaching, research and variety contribute more to academic satisfaction, whereas autonomy, physician-patient relationship, and coworkers contribute more to satisfaction for the physician in private practice. This study may be used when counseling residents concerning their career options.

Characteristics of Physicians Who Frequently Act as Expert Witnesses in Neurologic Birth Injury Litigation

OBJECTIVE

Much debate surrounds physicians who testify in controversial types of medical malpractice litigation, but little is known about them. We sought to describe characteristics of physicians who frequently act as expert witnesses in neurologic birth injury litigation.

METHODS

Using jury verdict reports, we identified 827 cases between 1990 and 2005 involving birth-related neurologic injury to a child. Frequent expert witnesses were defined as those associated with more than 10 cases. From the verdict reports and other public data sources, we compiled case descriptions (injury type and severity, legal outcomes) and characteristics of the frequent witnesses (age, gender, board certification, academic publication record). We analyzed these characteristics by comparing witnesses with each other (plaintiff compared with defendant) and with nationally representative data.

RESULTS

Seventy-one frequent witnesses participated in 738 cases (89% of the sample), which paid 2.9 billion US dollars in compensation. Most (56 of 71) testified for one side in at least three fourths of cases, and 40% of cases were located outside the witnesses' home states. Frequent plaintiff witnesses had a higher median annual case rate than their defendant counterparts (2.9 compared with 1.9 cases, P=.002). They were also older (57.2 compared with 50.8 years, P=.007), less likely to have subspecialty board certification (38% compared with 95%, P<.001), and had fewer academic publications (5.0 compared with 53.5, P=.002).

CONCLUSION

A small cadre of physicians testifies in most neurologic birth injury litigation, and witnesses tend to act consistently for one side. Plaintiff witnesses have fewer markers of expertise than defendant witnesses. These descriptive and analytical findings may reflect suboptimal expertise or bias in physician expert testimony.

Factors detracting students from applying for an obstetrics and gynecology residency

OBJECTIVE

This study compares perception about the characteristics of obstetrics-gynecology (OG) of medical students who choose to pursue a residency in OG and those students who choose to enter another specialty.

STUDY DESIGN

Fourth-year medical students were asked to complete a survey addressing their perceptions about OG. Responses were compared of (1) those entering OG to those entering other specialties, (2) those entering OG to those who seriously considered entering OG but chose another discipline, and (3) males to females. Chi-square tests were used for the comparisons.

RESULTS

Of the 267 eligible students, 137 (51.1%) completed the survey. Clerkship satisfaction was rated as high by 88.9% of students choosing OG vs 10.2% (P<.0005) of those who chose another discipline. The emerging predominance of female providers detracted 38.5% of males vs 10.2% of females (P<.0005).

CONCLUSION

Student perception of an OG clerkship may detract them from pursuing OG as a career.

Professional liability claims and Central Association of Obstetricians and Gynecologists members: myth versus reality

OBJECTIVE

The purpose of this study was to survey members of the Central Association of Obstetricians and Gynecologists about professional liability claims.

STUDY DESIGN

A survey was mailed to Central Association of Obstetricians and Gynecologists members regarding medical liability experience.

RESULTS

Of the 897 surveys mailed, 73% were completed. The responding 658 clinicians had been in practice for 17,136 years and had 1507 closed claims. The respondents had a claim every 11 years of practice and a trial every 69 years. Matched for years of practice, a case control comparison indicated that the litigation is significantly lower for female physicians (1.5 +/- 1.8) than for male physicians (2.2 +/- 2.0; P = .019) although the mean cases that were dropped or dismissed were higher for men (1.3 +/- 1.7 vs 0.8 +/- 1.4; P = .022). However, the mean number of trials, defense trial verdicts, and the settlement amounts were similar for both genders.

CONCLUSION

We found that professional liability claims are uncommon and that the gender of the obstetrician-gynecologist influences the litigation profile.