Our Delivery Practice Is Faltering
Dr. Lerner's colleagues are not alone. Faced with daunting increases in malpractice premiums, U.S. obstetricians are abandoning the childbirth specialty in droves. The American College of Obstetricians and Gynecologists claims that in 1984-85, a period in which some members saw their premiums doubled, an estimated 12.3 percent of the nation's 17,000 practicing obstetricians stopped delivering babies. In Florida, the worst-hit state, one in four obstetricians quit. Those who didn't paid premiums of up to $118,000.
The malpractice insurance problem has affected several high-risk specialties, but obstetricians are particularly vulnerable because of the fragility of newborns, in whom the slightest error can cause irreparable damage. Parents are also unquestionably more litigious. Ten years ago only one in 20 obstetricians was sued for malpractice. Last year one in six was sued. "Everybody expects a perfect baby," says Dr. Kelley Avery, former medical director of a malpractice insurance company in Nashville. "When it is not perfect, there is almost always a lawsuit, and the damages reach startling levels."
One result is that obstetricians are now practicing more defensive (and costlier) medicine—making more diagnostic tests, advising second and third opinions and turning away risky cases. Nationwide, several hundred doctors now subscribe to Physician's Alert, a computer service that keeps data on malpractice claims and warns of habitually litigious patients. The Detroit-based company claims that 35 percent of malpractice plaintiffs have a history of filing lawsuits.
Beleaguered obstetricians argue that responsibility for the malpractice crisis rests with ambulance-chasing attorneys. In fact, there is evidence that only a small percentage of actual victims of malpractice ever take their doctors to court. Ironically, those who do win malpractice settlements generally collect only 28 cents on the dollar; the rest goes for legal expenses. "It is insanity," says Dr. Harry Jonas, president of the American College of Obstetricians and Gynecologists, "and all of us—physicians, patients and taxpayers—are losing."
What follows is a report on the victims of the malpractice insurance crisis, and the search for a solution.
A pregnant teen faces a long day's journey
Clutching her blue overnight case and a tote bag filled with baby clothes, 16-year-old Lucella George climbs into the brown Ford pickup beside her 22-year-old husband, Doug. More than eight months pregnant, she faces an arduous four-hour round-trip journey across desert and mountains to keep her appointment with an obstetrician. Lucella has been making the 110-mile trip from her hometown of Schurz, Nev. to Reno once a week since March, when her family doctor gave up obstetrics because of soaring malpractice premiums. "I feel like I was abandoned," she says. "I only see this new doctor for five minutes. I'm scared of the pain and I worry about things going wrong."
A teenage pregnancy carries higher than normal risks, and the problems facing Lucella could add to the hazards. Not surprisingly, she dreads the idea of having to make the trip to Reno while in labor. "Being so young and having a baby is scary anyway," she says. "I wake up in the night worrying. What if the labor pains come fast? I guess I'll have to stop on the side of the road." There might not be anyone to drive her there. Doug works at a construction job 40 miles from home and her mother, Donna Glazier, a licensed practical nurse, works in Hawthorne, 35 miles away. Money is also a concern. Lucella has medical coverage for her visits to the low-income maternity clinic in Reno, but each trip costs $40 for gas and food, cutting deep into Doug's $225 weekly salary.
Lucella hopes that her obstetrician, Dr. Harold Chotiner, will agree to induce labor. But after a check with the fetal heart monitor shows that her baby is doing well, Lucella may have a week or more to wait. Dr. Chotiner tells her for the first time that if there is an emergency, she should just go to her nearest hospital. But since there is no longer a practicing obstetrician in Schurz (pop. 325), even the promise of being airlifted to Reno provides scant comfort. "I'm so discouraged and tired," she says as she begins the long ride home. "I just want this to be over."
In Illinois, a revered doctor calls it quits
Standing in the nursery of the Harrisburg Medical Center, cradling a 7-lb. 4-oz. newborn she had delivered by cesarean section just five hours earlier, Dr. Cynthia Fraed fights back tears. "All of a sudden it's dawning on me that this is the end," she says. "I only have nine deliveries left. This has been a significant part of my life. I think the beginning of postpartum depression has set in."
At midnight on June 30, the 38-year-old obstetrician-gynecologist, who has been "hooked on catching babies" for 14 years, will shut down her obstetrical practice in Harrisburg, Ill. From then on, she says, she will limit her work to gynecology. The reason: Her medical malpractice premiums have gone from $17,000 in 1984 to $26,000 in 1985 to $40,000 this year. "It has gotten to the point where the risk outweighs the benefits," she says. "Obstetrics used to be called 'the happy specialty' but now it's become a nightmare. I was beginning to feel like a sitting duck, that I had to guarantee each child would be born healthy and normal."
Cynthia Fraed decided to become an obstetrician when, as a third-year med student, she found herself suddenly presiding over a premature birth. "I'll never forget delivering this tiny, 2-lb. 8-oz. girl named Tiffany," she recalls. "I watched her in the hospital for weeks." After serving her residency at the St. Louis University hospital group, she joined a practice in Harrisburg nine years ago and became a local pioneer for more liberal labor and delivery procedures. She encouraged patients to take warm, relaxing showers during labor and permitted them to deliver in unconventional positions, standing, squatting or lying on one side. "She makes you feel like you're the only patient she has," says June Behrend, 22, whose daughter, Sarah, now 17 months, was delivered by Fraed. "It's like your mother or best friend is in the room with you."
About three years ago Dr. Fraed's enthusiasm began to cool. Soon after she had opened her practice with a loan of $120,000, she was hit with two lawsuits. She declines to discuss the cases, which are still pending, except to say that they changed her attitude toward her work. "I realized that you don't have to do anything wrong to get sued," she says. "I began practicing defensive medicine. Instead of writing on a patient's record sheet I began carrying a Dictaphone and having every detail transcribed. I also began approaching patients differently. I didn't get as close to patients because there was an element of suspicion-the chance that I might later be at odds with a patient. I was afraid to invest as much of myself as before." She began avoiding high-risk cases and moving more quickly to interrupt prolonged labors with cesarean sections.
Last February, attorney Judy Cape, 30, approached Fraed for obstetrical care and asked for assurances that the doctor would not intervene during the delivery—that she would under no circumstances use medication or induce labor. After three weeks of soul-searching Fraed told the pregnant lawyer to find another obstetrician. "She was asking for demands I could not in good conscience sign," Dr. Fraed explains. "I did not know what might happen during delivery."
Then, last December, after receiving her latest malpractice insurance increase, Dr. Fraed decided to retire from the field she still loves. The new premium was prohibitive not only for Fraed but also for her patients in the economically depressed rural area. One-third of her OB patients are on public aid, which covers only 40 percent of her $825 delivery fee. Before, she had absorbed the difference. "I really thought I had a moral responsibility to take patients who couldn't pay," she says. "All I wanted to do was break even." Given the new malpractice premiums, she no longer could.
Many of her patients were heartbroken when they heard she was quitting. "I cried when I found out," says Pam Alecci, 26, now pregnant with her second child. "During my first pregnancy, I went through 20 hours of labor and Dr. Fraed never left me. She was very comforting." Fraed has regrets, but believes her decision is correct. "I don't want to be in a situation where I have to determine my own risk versus the patient's risk," she says.
Then there was one: Dr. Goolsby hangs in
In February, Dr. John Adams, a family practitioner in Cordele, Ga., announced that, because of rising malpractice insurance rates, he would no longer take obstetrical patients. A few weeks later another Cordele physician, Dr. Henry Young, said that he was also quitting, for the same reason. That left only one practicing obstetrician in the town of 12,000—Dr. Louis Goolsby, 31. During a two-week period Goolsby found himself working at full stretch delivering new babies. "Between March 1 and March 12, I delivered 15 babies," he says. "I was worn out. I didn't get to sleep or eat. At this rate, if I were the only OB in town, I would be delivering 40 babies a month. You wouldn't have time to document the cases. You wouldn't have time to explain. Never mind what a schedule like this does to your judgment. It was awful."
It was so awful, in fact, that by the end of the month, the shell-shocked physician announced that he too would have to consider quitting obstetrics unless he could persuade at least one other obstetrician to join him in the town. "The pressure, the fatigue, the anxiety I experienced those two weeks after Adams and Young quit forced me to consider phasing out OB," he says. "I had absolutely no family life, no time even to eat. Those two weeks were like somebody was trying to tell me something, saying, 'This is the way it's going to be....' "
Dr. Goolsby has decided to continue practicing obstetrics and is willing to pay his own high malpractice insurance rates—$32,000—at least until the end of the year. In the meantime, he is beating the bushes for a little assistance, interviewing obstetricians and midwives. Thus far he has found no takers but remains hopeful. "I am going to solve this problem," he says. "I'm determined to get another OB in. If things don't get any worse, I plan to do OB as long as I can. It gives you a lot of pleasure. I don't think there's anything better than the feeling delivering a baby gives you. Other patients have a disease they don't want. Obstetric patients have a baby they do want."