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Where Have All the Doctors Gone
By Marielena Zuniga
A few months before her baby was due to be born, Melinda Sallard* of McNeal, Arizona, lost her ob-gyn. No longer able to afford massive malpractice fees, her doctor and her hospital stopped providing maternity care. When Sallard began contractions at 1:30 in the morning, she and her husband had to drive one hour and 45 miles away to the nearest hospital, even though the hospital where her doctor had been on staff was 15 minutes away.
Rushing across desert roads as fast as he could, her husband watched as his wife began delivery, in the dark, in the front seat of their car. Melinda gave birth on the side of the highway, in the middle of nowhere. Then the situation became terrifying. The baby was not breathing or crying.
Laurie Peel** of Raleigh, North Carolina, also lost her doctor. New to the area and 11 weeks pregnant, she was experiencing complications. She contacted ob-gyn offices for an appointment, but over and over was told they were full and not taking new patients. She was happy when Dr. John Schmitt took her in.
“In short, my relationship with Dr. Schmitt was everything one could hope for in a doctor,” Peel says. “It was also a relationship both he and all of his patients wanted very much to continue.”
But it didn’t. Dr. Schmitt had to leave his practice because his insurance premiums jumped from $17,000 to $46,000 in one year. What he had to pay to protect himself from the remote possibility of lawsuits prevented the doctor from continuing the practice he had made his life’s work. Today, Dr. Schmitt teaches at the University of Virginia.
Dr. Shelby Wilbourne** was in the same situation. His medical-malpractice premium rose to $108,000 from $33,000 the previous year. So he packed up his belongings, left his Nevada practice and moved to a coastal town in Maine, where his insurance fees were lower.
“When I left Nevada, my patients, many of whom were with me for 12 years, were forced to find another ob-gyn amongst a dwindling population of ob-gyns in Nevada,” he testified before the U.S. Congress. “This is the real issue. Patients around the country are losing access to good doctors and quality health care. The end game of the current system is a society without enough doctors to care for its citizens. We just cannot let this happen.”
The ob-gyn shortage isn’t only happening in the United States. In the fishing community of Oki Island, Japan, pregnant women lost their only obstetrician and were asked either to deliver at faraway regional hospitals or to expect an emergency helicopter ride across 40 miles of water to the nearest functioning maternity ward. And the lack of ob-gyns is so severe on Hokkaido and Shikoku, two of Japan’s four main islands, that some births are induced to coincide with a doctor’s availability.
Is there an ob-gyn crisis?
The stories go on and on. They are real and affecting women who have had longstanding relationships with their ob-gyns and are finding office doors closed. But is there a legitimate crisis of ob-gyns who no longer practice in the United States, Japan and other parts of the world?
It depends on location. Certainly rural areas are hit hard, in Japan and the U.S. But then so are major cities like Philadelphia and its suburbs, where 14 hospitals have recently discontinued obstetric services.
According to an American College of Obstetricians and Gynecologists (ACOG) <www.acog.org> survey, almost 70 percent of ob-gyns have made changes to their practice because of the lack of available or affordable medical liability insurance, including reducing the number of high-risk patients they care for. In addition, 7 to 8 percent have stopped practicing obstetrics altogether. In Japan, fewer than 8,000 doctors were delivering babies in 2005, according to the Japan Society of Obstetrics and Gynecology <www.jsog.or.jp>. And a Japanese newspaper survey reported that 105 hospitals had closed or had decided to close their obstetric units between April 2006 and March 2007.
Other parts of the world are also experiencing the ob-gyn crisis. Some women in Toronto are waiting three to six months to see an obstetrician, with the Society of Obstetricians and Gynecologists of Canada (SOGC) <www.sogc.org> describing the situation as “critical” in Canadian cities. Soaring malpractice rates and fear of lawsuits among ob-gyns in France are also causing a crisis there. Many ob-gyns in that country are being forced to close their practices, with experts predicting a “dire shortage” in prenatal care.
This scarcity of services directly impacts expectant mothers, who want and need to deliver healthy babies but often find themselves without care, according to Senator Judd Gregg (R-NH), sponsor of the “Healthy Mothers and Healthy Babies Access to Care Act of 2003” (S.244). The bill would improve women’s access to health care services and provide improved medical care by reducing the excessive burden the liability system places on the delivery of ob-gyn services.
In a floor statement, Judd called the situation a “crisis,” with the American Medical Association identifying 21 states already in crisis and another 22 seeing warning signs of a potential crisis. “In the end, who’s the loser?” Judd asked in his statement. “The losers are the doctors who can’t practice what they’ve been trained to do. And the losers are the women, especially in rural areas, who can’t see a doctor if they are having a baby.”
A malpractice maelstrom
How did this situation get so bad? Some say it’s a combination of legal, social and generational factors that have converged into the “perfect storm” for ob-gyns, and the resulting lack of access to care for women.
The medical liability crisis is key, says Dr. Lisa Hollier, associate professor at University of Texas, Houston, Lyndon B. Johnson Hospital Program. “The high cost of liability insurance has caused a number of physicians to either consider not entering the ob-gyn specialty, or have forced physicians already in practices to make important changes regarding the care they provide for women,” she says.
Dr. Mary Jane Minkin, clinical professor of ob-gyn at Yale University School of Medicine, gave up the obstetrics part of her work, and now provides only gynecological services as part of a group practice in New Haven, Connecticut. During a five-year period, she saw annual liability insurance rates jump from $32,000 to $90,000 per doctor.
“These are reduced rates for Yale faculty,” says Dr. Minkin. “Out in the real world, I’d be paying a rate of $150,000 and writing a check for the privilege of staying up all night. The thing is, I’m really pretty good at what I do.”
The liability issue is also hitting ob-gyns in Japan, but other factors, such as a rapidly aging population among doctors, declining birth rate and challenging working conditions have led to significant drops in the number of obstetricians there. As a result, women in some areas have no doctor during their pregnancies, says Dr. Akiko Ohno, department of ob-gyn at Keio University School of Medicine in Tokyo.
“The perinatal morbidity in Japan is the lowest in the world,” says Dr. Ohno, “and that’s something we can be proud of. But many ob-gyns, including myself, feel that the maternal care system is fraying at the edges and there is no strength left.”
In Japan, small clinics staffed by one or fewer ob-gyns used to care for expectant mothers. This system was supported by hard-working doctors who gave up their personal time and worked around the clock, Dr. Ohno says. Then, obstetricians in Japan were shocked when a doctor in Fukushima Prefecture was arrested for negligence after a pregnant woman under his care died from an obstetrical hemorrhage during childbirth.
“He was the only ob-gyn at that hospital,” Dr. Ohno says, “and many clinics and hospitals supported by only one ob-gyn were forced to close down … the fact that it is being tried as a criminal case only added despair to many sole ob-gyns. Now, in many rural areas, expectant mothers have to travel great distances for their routine check-ups, as well as for their delivery.”
Fewer and fewer ob-gyns
Women physicians especially struggle to balance the demanding hours of an ob-gyn practice with the demands of their families. Many women ob-gyns don’t want to practice full-time, yet there are few part-time malpractice premiums, says Dr. Minkin, who in 1976 was the second female ob-gyn resident at Yale-New Haven Hospital. “My junior partner had her second baby and was working one less day a week, yet she was paying a full premium,” she says.
When Dr. Rajiv Gala attended a 2005 symposium of international ob-gyns in Kyoto, Japan, he heard the issue addressed informally a few times.
“A number were struggling over future career plans and how to balance both,” says the assistant professor at UT Southwestern, Department of Obstetrics and Gynecology, in Dallas, Texas. “My sense was that it was more than demanding hours, but in part rooted in the culture, and their families wanted them to make a commitment one way or another. While in Japan, I was also surprised to learn that in the entire country there was only one female professor of ob-gyn at that time.”
In addition, more experienced American ob-gyns are leaving their practices, retiring at an average age of 48. In Canada, 34 percent of the 1,000 obstetricians who are still delivering babies plan to retire in the next five years, according to the SOGC. Balance that with the next generation reluctant to enter the profession and it becomes a double-edged sword in many countries. “You have a population of doctors who are aging, but at the same time, you’re having a situation where young doctors are not entering the field,” says Dr. Gala.
With terrible work hours and increases in malpractice litigation, students who once had an interest in the profession are holding back, Dr. Ohno adds. “The medical treatment fees are set unreasonably low and it doesn’t pay off for the time, risk or burden. With so much risk, the satisfaction and feeling of reward when seeing the happy faces of new mothers may not be enough to recruit new ob-gyns anymore.”
Medical students are savvy, adds Shawn Martin, chair of the Health Coalition on Liability and Access <www.hcla.org> in Washington, DC. “They are aware of the environment they’re entering and when they look at future careers, they pick up on what is high risk, low risk and make choices. The danger in practicing ob-gyn has become so great, that one in three residents, even before they go into a private practice, has been sued.”
As more ob-gyns retire, the profession and women are losing the skills of those providers who may be able to offer specific services, like vaginal breech or forceps deliveries. “We’re losing a wealth of experience,” adds Dr. Hollier.
Dr. Ohno saw the demands of the profession on older ob-gyns when she worked for a general hospital during her third and fourth years of training. Her department supervisor, in his 50s, would take almost as many calls as she did, she says.
“If he didn’t, others would have to do 10 calls or more. I don’t think I’d have that kind of strength left in my 50s,” adds Dr.Ohno, “Yet, I’ve heard the situation is far more devastating in provincial areas. In many hospitals, there are only one or two ob-gyns and they are getting too old to hold down the fort. They are starting to retire, with no new ob-gyns to take the posts.”
Diminished access to care
Whether it’s rising premiums and dropping health-care reimbursement rates, or demanding hours and crazy schedules for ob-gyns, the end result is the same: diminished access to care. More and more women must cross state lines or travel longer distances to deliver their babies. And women who are poor and have high-risk pregnancies have even greater difficulty finding doctors.
JoAnne Fischer and Letty Thall of the Maternity Care Coalition <www.momobile.org> in Philadelphia, Pennsylvania, have witnessed the crisis firsthand. While the birthrate in the Philadelphia area remains steady, 14 hospitals in the area have closed their maternity units, three in one year alone. Each closure puts more pressure on remaining hospitals for service, increasing the chances that they, too, will stop providing care.
The group’s 2006 report, “Childbirth at a Crossroads,” looks at diversity, access, care, equity and support, and an environment where “maternity care is considered unprofitable” for hospitals. It argues that the economics of obstetrics and modern hospital practice have affected the services and care a woman receives.
“When we wrote our report, we didn’t want to say it was a crisis,” says Thall, public policy director for the nonprofit women’s health advocacy organization. “Since that time, two more hospitals in one neighborhood have closed. We are now in a crisis.”
Fischer, the group’s executive director, says that women have become anxious not knowing where they will deliver their babies. “It’s really disorienting for women who assume everybody is in place. I recall a woman who was signed up at a local hospital and they were closing around her due date,” Fischer says. “So she scheduled a C-section so she could have the baby before the hospital closed. This was really frightening to her.”
Women are also affected during their hospital stay. The report states: “Insurers expect women to be discharged promptly. Mothers may leave the hospital without the results of newborn screenings … and opportunities for education of new mothers have diminished considerably.”
Searching for solutions
The medical community and other groups are scrambling to find solutions, such as advocating for liability reform, hiring laborists and establishing health courts (see sidebars). But while everyone struggles to find answers, the growing shortage of ob-gyns continues to take a toll on mothers and their children. Dr. Hollier recalls an ob-gyn who had a practice in Fredericksburg, Texas, but had to quit because of rising liability insurance.
“People recognized what that would mean if she left. Being the only ob-gyn in Fredericksburg was a reality for her patients. You live in this rural area of central Texas and suddenly, do you have to drive one-and-a-half hours to Austin while you’re in labor? I can’t visualize myself doing that.”
Women especially have a problem when a complication with a pregnancy or an emergency arises, Dr. Gala says. “Women can’t wait. Still, it may be a three-hour drive, or a helicopter flight into a major tertiary center having services available to take care of the mother and premature baby. You may not have resources available in a smaller city and that’s where women get disproportionately affected.”
While some are hesitant to correlate the growing shortage of ob-gyns to infant mortality rates, they admit concern. In Virginia in 2003, for example, as the number of obstetricians decreased, the number of infant deaths rose to 766, the state’s highest number in nine years.
Dr. Gala wants women to know, especially those in other countries, that physicians are acutely aware of the problems patients are facing and have been rallying to become advocates for their patients. But patients also have as much power, if not more, to advocate for their care. “So be politically active, talk to your representatives to explain the situation,” he says. “That’s where the women of Japan and the U.S. can show their power.”
For Melinda Sallard, giving birth on a desert roadside was frightening. But she was fortunate. She was able to start her infant’s breathing and today her daughter is a healthy, happy 5-year-old.
“I was able to save my baby,” she says, “but no mother should have to go through what I did. So, call your Senator before it’s too late for someone else.”
(*Melinda Sallard’s story was adapted from a national advertising campaign advocating medical reform liability. **Laurie Peel’s and Dr. Shelby Wilbourne’s comments were adapted from their Congressional testimonies before the Senate Judiciary Committee in 2003 on “Patient Access Crisis: The Role of Medical Litigation.”)
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