Difficulties with laborist system.(LETTERS)(Letter to the editor)

Many large single-specialty groups, including Kaiser Permanente, assign a physician to cover only labor and delivery for 12- or 24-hour blocks in house ("Laborist Movement Poised to Take Off," June 15, 2005, p. 1).

Such a system does offer patients prompt, continuous, and efficient care. The only difference between this system and the system proposed by Dr. Louis Weinstein is that in his system, there is no possibility of a woman being attended by someone she has met for prenatal care. Having worked in systems where that occurs, I can attest that it does not increase patient satisfaction.

The other difficulties I have with his proposal are economic and philosophical. Economically, where is he getting paid $1,200 for delivery fee only? In my marketplace, it is less than half of that. A hospital in my market needs to have more than 300 deliveries per month for it to make economic sense to have a physician in house.

Further, if he is willing to cover the malpractice of the physicians, where is he booking the potential liability for the cost of the tail on the policy when the hospital volume dips below his breakeven point or the administration changes and decides not to provide the service any longer?

Finally, since the majority of deliveries are low risk and can be attended by mid-wives, the laborist movement begs the question as to whether generalist obstetricians should be delivering infants at all. A more cost efficient system would be an in-house midwifery service with perinatology backup. Then the hourly cost for the system can drop from $90/hour in Dr. Weinstein's model to $60/hour with a commensurate decrease in the cost of the benefits package and the malpractice cost. The income saved can be allocated to the cost of the perinatologist who can also generate income through consultation. Or, if one wishes to be more humane, one can use the savings to hire enough full-time midwives to allow the patients to be seen in the clinic by caregivers who also attend in the hospital.

I predict that if the laborist movement takes off, we will see our more educated patients choosing midwives and hiring doulas. We will also see family physicians and others who can provide prenatal care doing so and then directing the patients to the hospital for delivery by the laborist. The perinatologists can ...