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

Forensic Obstetrics and Clinical Risk Factors

Forensic obstetrics attracts much attention from forensic experts and the public owing to the professional, legal, public health, and not inconsiderable social-emotional aspects and directly correlates with maternal, fetoneonatal, and iatrogenic risk factors. Modern obstetrics and fetomaternal medicine must not be quantified and qualified based only on perinatal disease but also according to current obstetric problems that burden forensic obstetrics. Therefore, high-risk obstetrics as a significant medico-legal problem should be viewed from the point of view of the entire perinatal period with possible long-term consequences, hence the monitoring of complete perinatal and infant morbidity is of immediate importance for quality control and risk control in the profession. The task of forensic obstetrics is to assess the impact of risk factors on the occurrence of an adverse event and to assess whether it is an obstetric complication or obstetric malpractice. Acknowledging the mentioned facts is the only way we will develop high obstetric awareness, and we and pregnant women, birth attendants, midwives and patients, fetuses, and newborns will have professional safety with imminent but controlled obstetric risk and controlled expected complications. On the other hand, the fact that the statistics of perinatal (obstetrical) malpractice globally is not abating requires a change in obstetrical philosophy, especially the unreasonable epidemic increase of cesarean sections with a significant percentage of cesarean sections without medical indication and complications. It is necessary to introduce and maintain solid professionalism and bioethical norms in obstetrics with constant training of skills, which is emphasized by numerous authors and with which we fully agree. Forensic obstetrics is based on the principles of good clinical practice, professional guidelines of modern obstetrics, and ethical and deontological principles. It clearly shows the perfection and imperfection of biological systems that we can and cannot influence. However, we must act according to the rules of the clinical profession, deontological rules, and health laws to reduce clinical risk to the smallest possible extent. Attention should certainly be focused on reducing the disproportion between iatrogenic and maternal-fetoneonatal risk factors, which is the most common reason for litigation today.

Conceptualized framework for levels of obstetric care

It has been demonstrated that risk-appropriate perinatal and obstetric care can improve perinatal morbidity and mortality. Recently, various studies focus on the importance of evaluation for maternal conditions and allocation of high risk pregnant women to highly qualified facilities. Therefore, it is necessary to develop the conceptualized framework for levels of obstetric care and establish the guidelines for the situations that should be cared in each level of facility. In this review article, we reviewed several classifications of obstetric care in eastern and western countries, and conditions in which transfer should be recommended depending on the risk and capacity of centers.

Frequency of satisfaction and dissatisfaction with practice among rural-based, group-employed physicians and non-physician practitioners

BACKGROUND

Widespread dissatisfaction among United States (U.S.) clinicians could endanger ongoing reforms. Practitioners in rural/underserved areas withstand stressors that are unique to or accentuated in those settings. Medical professionals employed by integrating delivery systems are often distressed by the cacophony of organizational change(s) that such consolidation portends. We investigated the factors associated with dis/satisfaction with rural practice among doctors/non-physician practitioners employed by an integrated healthcare delivery network serving 9 counties of upstate New York, during a time of organizational transition.

METHODS

We linked administrative data about practice units with cross-sectional data from a self-administered multi-dimensional questionnaire that contained practitioner demographics plus valid scales assessing autonomy/relatedness needs, risk aversion, tolerance for uncertainty/ambiguity, meaningfulness of patient care, and workload. We targeted medical professionals on the institutional payroll for inclusion. We excluded those who retired, resigned or were fired during the study launch, plus members of the advisory board and research team. Fixed-effects beta regressions were performed to test univariate associations between each factor and the percent of time a provider was dis/satisfied. Factors that manifested significant fixed effects were entered into multivariate, inflated beta regression models of the proportion of time that practitioners were dis/satisfied, incorporating clustering by practice unit as a random effect.

RESULTS

Of the 473 eligible participants. 308 (65.1 %) completed the questionnaire. 59.1 % of respondents were doctoral-level; 40.9 % mid-level practitioners. Practitioners with heavier workloads and/or greater uncertainty intolerance were less likely to enjoy top-quintile satisfaction; those deriving greater meaning from practice were more likely. Higher meaningfulness and gratified relational needs increased one's likelihood of being in the lowest quintile of dissatisfaction; heavier workload and greater intolerance of uncertainty reduced that likelihood. Practitioner demographics and most practice unit characteristics did not manifest any independent effect.

CONCLUSIONS

Mutable factors, such as workload, work meaningfulness, relational needs, uncertainty/ambiguity tolerance, and risk-taking attitudes displayed the strongest association with practitioner satisfaction/dissatisfaction, independent of demographics and practice unit characteristics. Organizational efforts should be dedicated to a redesign of group-employment models, including more equitable division of clinical labor, building supportive peer networks, and uncertainty/risk tolerance coaching, to improve the quality of work life among rural practitioners.

Patient and Practice Characteristics: Impact on Career Satisfaction of Obstetrician-Gynecologists

This study examined demographic and practice characteristics that affect the career satisfaction of obstetrician-gynecologists. Data were retrieved from the 2008 Health Tracking Physician Survey, conducted by the Center for Studying Health System Change. The survey consisted of a nationally representative sample of physicians belonging to the American Medical Association. A final sample of 290 obstetrician-gynecologists was obtained from the study. Results indicated more than 80% of obstetrician-gynecologists were either "somewhat satisfied" or "very satisfied" with their careers in medicine. Nearly 56% were older than 48 years; 59% of respondents were men and 77% were of white race. The average obstetrician-gynecologist worked 54 hours per week in medically related activities. Regression analysis showed a significant relationship between obstetrician-gynecologist career satisfaction and the following: adequate time with patients, perceived quality of care, income, work hours, and revenue from Medicaid. In addition, Hispanic patients and the presence of formal written guidelines had a positive impact on career satisfaction. It was concluded that quality care, time with patients, work hours, and income are the major predictors of obstetrician-gynecologist career satisfaction. Further research is needed to understand the relationship between patient demographics and career satisfaction.

Lessons for providers and hospitals from Philadelphia's obstetric services closures and consolidations, 1997-2012

The Affordable Care Act is triggering an increase in hospital consolidation and mergers. How other hospitals respond to these disruptions in supply could influence patient outcomes. We examined the experience of Philadelphia County, Pennsylvania (coterminous with the city of Philadelphia), where thirteen of nineteen hospital obstetric units closed between 1997 and 2012. Between October 2011 and January 2012 we interviewed twenty-three key informants from eleven hospitals (six urban and five suburban) whose obstetric units remained open, to understand how the large number of closures affected their operations. Informants reported having confronted numerous challenges as a result of the obstetric unit closures, including sharp surges in delivery volume and an increase in the proportion of patients with public insurance or no insurance. Informants reported adopting a number of strategies, such as innovative staffing models, to cope with the added demand brought about by the closure of nearby obstetric units. Informants emphasized that interhospital communication could mitigate closures' stresses on the health care system. Our study supports the need for policy makers to anticipate reductions in supply and monitor patient outcomes.