Monday, March 29, 2010

Answers for A

I recently received a comment on the blog posing the following questions. At first, I was going to just correspond via email, but I thought perhaps my readership could also jump in on answering these questions from "A," a 3rd year medical student considering Ob/Gyn. So, thank you in advance for your help!

Hi Dr. Whoo,

I have thoroughly enjoyed reading your blog and appreciate the time and effort you put into your posts to provide us readers with a glimpse of your life. I am currently an MS III with only 6 months left to decide on what to do with my medical career. My top 3 choices are OBGYN, Anesthesiology and Psychiatry. I loved my OB rotation and feel that the field is a perfect blend of medicine, surgery, procedures and primary care.

Hello, A! Thank you for the nice words about the blog, I am glad to be able to provide a glimpse of life in the world of Ob/Gyn. I agree that Ob/Gyn is a perfect blend of medicine, surgery, procedures, and primary care. It is a really great field, but it does have its limitations.

However, I am afraid to commit to the field for the following reasons:

-Work hours. I cannot get a straight answer from the academic faculty on what to expect after residency. Most of them have flat out discouraged me from choosing OB, telling me that I should just do one of my other 2 choices. Is it possible to find a job working 60-65 hours/week and still come out with a salary of $250-$300k in smaller cities in midwest or the south? I just want to be well-informed of what to expect before I take the plunge to ensure that I don't end up hating my career .

HAHAHAHAHAHAHA! Ahem, I mean, ah, not likely right off the bat, at any rate. I think you can get the salary you want with more work hours, or the work hours you want for a lower salary, but it would be rare to find the above combination just out of residency. My average work week (5 person group practice) is right about 60 hours with weekday call, 110 hours for weeks where I have weekend call. As an employed physician, I make less than $200,000. My pay will increase with each employed year until I am able to "buy-in" to the practice. After that, my income will increase (but a large portion of it will go back into buying into the practice). After about 5 years of "paying my dues," I will be able to set my ticket for income. It just takes some time.

At my previous job, I made over $250,000, worked in a rural, under served area with high Med.icaid, and only had 4 days off per month, so 168 hours the weeks that I worked weekends, 120 hour weeks the weeks when I had the weekend off. Trust me, it is far better to make less money and work less hours, especially now when looms on the horizon. (Plus, think of the taxes you will be paying on a higher salary, you may get to keep more of your money working for a lower income.) So, while I am sure you can find some places where low work hours and higher income combines, that would certainly not be the norm until you establish a practice.

-Liability. How stressful is this aspect of OB if I choose to move to a state with Tort Reform or low liability?

Liability, Tort Reform or not, is always stressful in OB. It will loom over your shoulder with every decision you make, especially with respect to managing labor and delivery. Even when you uphold the standard of care, you can still be sued for bad outcomes, and all it takes is one case to destroy you financially, personally, and professionally. Malpractice premiums are fairly exorbitant in the field, as well. You may not be able to cover your malpractice costs if you have a poor payer mix, meaning more volume, which leads to more chances of things going wrong. Vicious cycle. Most of the time, it is just like static noise in the background, other times you hear the alarm bells clanging. You get used to it, but it is always there.

-I am a male (a minority in the pool of OB applicants). I have been told that being a male would make it difficult for me to find a decent job because practices tend to prefer women OB's (hence males have to settle for worse locations, work hours and call schedules). How true is this?

Well, to be honest, I am not sure, since I am not a male. (Any male Ob/Gyns out there want to field this question?) I know that in many of the positions for which I interviewed, they were very interested in procuring a female physician. One field that you may consider, if you are so inclined, is the field of Urogynecology. I think it is a 3 year specialty after residency. It is a more surgery-heavy specialty, and, in my experience, still fairly male-dominated. You still get some procedures, good primary care and a lot of good surgeries, no babies, so less liability, and likely better hours and compensation overall. I hope that these answers helped somewhat, and I hope my readers are able to clarify further some points I am not able to elaborate upon. I truly wish you the best of luck with the rest of your training, and in whichever specialty you choose to pursue.

Thursday, March 11, 2010

Dropping In and Frustration

Since my move from Whooville to Newville, I've had to make some adjustments to the new patient population. Perhaps the most frustrating of all, however, are the "drop-in" patients on Labor and Delivery. My previous hospital was a rural, community hospital. It was certainly off the beaten track, and the building? Was old. Really old. The L & D suites were certainly sufficient and functional, but luxurious? Not so much. You had to know where you were going to find the hospital, and it was quite the rare occasion to have patients just "drop-in" for care.

Not so for the new digs. This hospital is new. Pretty much Brand Spanking New, and posh, and beautiful, and, oh yes, right off of a major highway, visible for all the world to see. Which makes for the fascinating phenomenon that is the OB "drop-in" patient. "Drop-in" patients come to this hospital "because it is close," or "because it is nice," or "because it was on the way." So, what is so bad about working in a hospital in which everyone wants to deliver? Well, what is so frustrating is the women who *know* that they want to deliver at our hospital, but do not seek pre-natal care from physicians that cover our hospital. Therefore, any pre-natal labs or records, or history of complications are virtually inaccessible at the time that they come in for delivery. Often patients from the large, downtown academic center (who don't have insurance or have insurance not accepted by our practice) receive all of their pre-natal care "for free" at the downtown center clinics and the purposefully come to our hospital to deliver. The patients are often not troubled by this, and often seem mildly surprised that we "aren't all the same" and have no way to access their records. After all, they are getting exactly what they want. It is much harder for us, as physicians, however, to help these patients. Especially when it comes to their expectations for delivery. It is difficult to develop a proper rapport in the few hours that we have with them. I think that trust is so important in the delivery room.

Even more difficult are the transient patients who stop in on their way through town, like one patient who had absolutely no pre-natal care, and was on her way to deliver her baby somewhere "non-medical" when her water broke, and she decided to stop-in at our hospital. She had, indeed, broken her water, but she refused an ultrasound to assist with proper fetal dating because she was concerned that the "x-ray waves" would damage the baby. She then proceeded to refuse any medical assistance from the hospital at all for over 24 hours, tying the medical staff's hands, and putting them at risk for liability at the same time. Eventually, she agreed to augmentation of labor, and even requested epidural analgesia after a prolonged labor. With medical assistance, she eventually was able to deliver, but the baby boy had definite signs of septicemia (likely due to prolonged rupture of membranes) and ended up in the NICU for over a week. When all was said and done, the mother, upon release from the hospital, said that she and her infant would never step foot in another hospital again, despite the fact that it was with the hospital's help that her child was born and made well when he was sick. To this day I will never understand why she "stepped foot" in the hospital from the start, if she did not want any intervention that the hospital could offer. This case brought a lot of issues that plague the medical profession in this day and age to the forefront.

Thankfully, her baby, despite some health issues at birth (that likely could have been avoided with faster intervention) did well...but what if he did not do well? What if the infant did not survive? Then who is at fault? The hospital? The physician? The mother? These are the questions the haunt physicians' sleep at night. Obstetrical interventions are not only done to avoid lawsuits, they are done to protect the safety and health of both the mother and her baby. However, one bad outcome, one wrong decision, can result in catastrophic professional, financial, and personal losses for the physician. Is it any wonder that we are hyper-vigilant? Is it any wonder that we would jump at any opportunity to prevent a bad fetal outcome, even it it means surgical intervention risks for the mother? It is thanks to Jon Edwards and others like him that the cesarean rates are rising, VBACs are being refused, that patients are being over-monitored, and that interventions are becoming the exception rather than the rule. Without tort reform, without the ability of the physician to operate from another position than that of fear of a poor outcome, then I am afraid that obstetrical care will remain the same in this country for years to come. Please consider that your rage just may be misdirected.