By Melinda Tuhus
Friday, June 4, 2004
The question, "Is there a doctor in the house?" is more likely to be answered in the negative when the doctor needed is an obstetrician.
NEW HAVEN, Conn. (WOMENSENEWS)--A year after being named obstetrician of the year in 2002 by Connecticut Magazine, Dr. Tracy Brennan stopped delivering babies.
The mother of five, who was working only three days a week, was not earning enough to offset the suddenly higher cost of her medical malpractice insurance, which in 2003 nearly doubled, going from $57,000 to $110,000.Regretfully, she decided to limit her 15-year practice to gynecology and gynecologicalsurgery.
"The tragedy is that of 40 ob-gyns who practice at Hartford Hospital," Brennan says, using the common abbreviation for women's reproductive health care, "15 have stopped doing obstetrics."
Her decision to drop obstetrics was heartbreaking, she says. "I'm 47 and I've never wanted to do anything else since I was 12."
Over the past 30 years, so many women have entered the field of ob-gyn that they now constitute almost three-quarters of the ob-gyn residents in the United States.
But Dr. Mary Jane Minkin, who in 1976 was the second female ob-gyn resident at Yale-New Haven Hospital, says that women are now leaving the field in droves. "We've seen dramatic numbers of women giving up the practice of obstetrics. And this is not a good thing for choice, because I think many women want female doctors."
Minkin says that many of those who are leaving are, like Brennan, mothers who want to spend time with their own children. They work less than full-time, but must pay for full-time malpractice insurance.
Data from the Physician Insurers Association of America indicates that in 2003 almost as many lawsuit claims were closed out (through settlement or jury verdict) against ob-gyns as against internists--992 and 1100. But ob-gyns comprise a much smaller segment (about 5 percent) of the total physician population than internists (about 17 percent.)
The American College of Obstetrics and Gynecology says 75 percent of its members have been sued at least once. In 2003, the organization surveyed a portion of its membership and found that, as a result of lawsuits or the fear of lawsuits and high medical liability insurance costs, 22 percent of respondents reduced the number of high-risk obstetric patients they accepted, 15 percent stopped doing vaginal deliveries for pregnancies subsequent to a Caesarian section and 14 percent stopped practicing obstetrics altogether, but kept their gynecology patients.
All these changes diminish women's access to care, according to a February 2004 bulletin from the American Medical Association. Among hundreds of examples, it cites hospitals in Arkansas, Pennsylvania and Florida that have been forced to close their maternity services; women who must cross state lines to deliver their babies and women with high-risk pregnancies who have great difficulty finding doctors.
The problem is compounded because, while many physicians have cut back or eliminated their obstetrical practice, fewer U.S. medical school graduates are choosing to pursue ob-gyn, according to five-year statistics from the American Medical Association. "They're voting with their feet," says Dr. Charles Lockwood, chair of Obstetrics and Gynecology at Yale-New Haven Hospital and an internationally recognized expert in infant pre-maturity.
In 2003, U.S. graduates filled just over two-thirds of available ob-gyn slots--the lowest percentage ever--while graduates of foreign medical schools filled 23 percent and 9 percent of slots went unfilled.
Members of the Association of Trial Lawyers of America bring most medical malpractice cases against obstetricians on behalf of parents whose babies have suffered some harm at birth.
In an effort to avoid being sued, obstetricians are increasingly delivering babies by Caesarian section, if fetal monitoring shows the slightest abnormality. But the increased C-section rate in the United States--now at 26 percent of all live births, according to the National Center for Health Statistics--has not reduced neo-natal mortality or the occurrence of cerebral palsy, a birth outcome that has prompted many of the lawsuits.
Both doctors and lawyers agree that only a small percentage of those who suffer harm file lawsuits, so there are no accurate data on the number of infants injured every year. But tens of thousands of people die or are injured each year in U.S. hospitals due to preventable medical errors, according to a 1999 study by the Institute of Medicine.
Several physicians interviewed for this story agree with attorneys that the medical profession doesn't do enough to discipline incompetent doctors. "There should be zero tolerance of adverse outcomes unless they're biologically impossible to prevent," Lockwood says. "We need more transparency among doctors, but that's hard to achieve when they are so terrified of being sued."
The number of lawsuits has not risen in recent years, but jury awards in the 30 percent of cases that plaintiffs win have skyrocketed. The median award for medical negligence in childbirth cases, $2,252,645, was the highest for all types of medical malpractice cases analyzed. In 2002, juries awarded $80 million in one birth injury case and $95 million in another, according to data from Pennsylvania-based Jury Verdict Research, an independent publication that maintains a nationwide database of more than 213,000 plaintiff and defense verdicts and settlements resulting from personal injury claims.
Lockwood says these high awards are largely driving the steep increase in medical malpractice insurance, a trend that began in the mid-1990s but has escalated recently. Factor in lower reimbursement rates from managed care and there's a financial crunch.
The American College of Obstetrics and Gynecology has called for legal reforms and specifically for a cap on damages for pain and suffering, something the trial lawyers' association opposes as unconstitutional.
Currently, 23 states have some kind of cap, but a spokesperson for the doctors' group says some of the caps have been ruled unconstitutional and some make exceptions for lawsuits filed against ob-gyns. Efforts to enact federal caps are stalled in Congress.
Minkin says without significant reforms, a medical crisis is on the horizon.
"We will see an increase in infant mortality and in maternal mortality. We'll end up with a few doctors doing the bulk of deliveries, and they will be the younger, less experienced docs because the older ones, with established practices, will be able to make a living doing just gynecology. If this is what the American people want, God bless 'em, but I don't think it's what they want."
Melinda Tuhus is a journalist based in New Haven, Conn. She specializes in stories about education, healthcare and the environment.
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