The Thrill Is Gone

What is more exciting than the playoffs, more riveting than a good mystery and more addictive than chocolate or sex? Delivering a baby! 

Many of my patients have asked me over the last year if I miss delivering babies. The answer is: yes and no. The high of delivery is hard to equal, especially when the baby is healthy and wanted. Unfortunately this high is extracted from a lot of hard work, long hours, irregular eating and all-out general exhaustion. These I definitely don’t miss. 

Why do obstetricians continue to work like dogs? It certainly isn’t for monetary remuneration, because reimbursements for deliveries are now similar to what they were in 1986 when HMOs started gaining ground. Here in Brooklyn this reimbursement is between $2800 and $3500. This includes 10–14 prenatal visits, innumerable phone calls both day and night, hours spent with the patient during labor (sometimes more than 12), several visits in-hospital after delivery and a post-partum visit. More often than not, it also includes filling out at least two disability forms - one for the employer before delivery and one for after. I would like to see a lawyer who would spend that many unbillable hours with, or working for, a client. Especially when many of these hours are spent between midnight and 7 am. To top it off, obstetricians are not reimbursed until 2–12 weeks after delivery. 

Let’s face it: you have to love it to do it. My son, a psychiatrist, did an OB rotation as a medical student and asked me, “Mom, how can you stand it? All that blood, those smells, and the gore of the OR.” I told this to another psychiatrist and he asked, “Don’t you just learn to tolerate it?” The answer is: no. You either have to love blood, guts and lochia (post-delivery discharge) or you can’t be an obstetrician. When I was a medical student I worked at a big-city hospital in Houston, and did about 55 deliveries myself. I remember that for two months I woke up feeling like I was drowning in blood.

Much like sex, delivery is immutable in its earthiness and messiness. The basics have not changed in thousands of years. We can dress it up and make it pain-free, but it is still a bloody mess often accompanied by mucus, urine, feces and vernix (cheesy substance surrounding newborns). And it ends with that primeval extra organ - the placenta. Also like sex, it is hard to explain the thrill of it to someone who doesn’t find it thrilling. I didn’t even bother explaining it to my son. You either feel it or you don’t. You know how you felt as a child when someone explained the mechanism of sex? It sounded gross! You see what I mean? If it were just about logic, it is gross. 

The other attraction of obstetrics is its humbling tendency to show that nature trumps mankind's best efforts. No matter how much we think we know and how much science we apply to the field, nothing on a labor-and-delivery floor happens according to plan. The patient who has had six previous children all in less than four hours takes 15 hours to deliver her seventh child, and the tiny patient who you worried would never make it through labor delivers in the admitting room before getting into labor-and-delivery. The patient with the short cervix who you admitted for premature labor four times during the pregnancy goes post-dates and has to be induced. As usual, nature makes a fool out of your knowledge of obstetrics. 

There are so many disincentives for doing obstetrics these days, I can’t see anybody practicing it in five years - at least not in a private-practice setting. In states like ours with no caps on suits, the yearly price for malpractice runs from $150,000 to $240,000. There are less suits than there were 10 years ago, but the average suit now pays out about $12,000,000. In New York City there are now only two insurance carriers who still cover private obstetricians (those who work in hospitals get coverage via the hospital). Most obstetricians now pay more than 50% of what they make on deliveries to the insurance company. And malpractice is not just expensive; it is corrosive. Make no mistake about it. If you are in practice long enough, you will be sued. Most OBs will be sued multiple times. Perhaps this is why the average age for a New York obstetrician to retire is in his/her forties. After four years of premed, four years of medical school and four years of residency, most people give up obstetrics after about 15 years, not much longer than they trained.

Delivery of a baby is an addictive, sensual experience. And it is an honor to share such an intimate life adventure with your patients. But can we expect that to outweigh poorly reimbursed, long hours (did I mention that most private obstetricians have to work the next day after missing sleep to pay the bills) and the expense and psychological distress of lawsuits? I missed so much of my children’s everyday lives when they were small and we celebrated birthdays and holidays all over the calendar but I wouldn’t change my life as an obstetrician. It was grand! But as B. B. King says, “The thrill is gone!” and I have now rejoined the human race and have begun to smell the roses. 

 

Comments

[Adriel Gerard]

This is a great blog piece with an important message. OB is a field in crisis, a fact of which I have found that the general public, even most doctors, are unaware. Something has to change sometime soon as this is a system that will not last with potentially disastrous consequences. My only gripe is that I could swear that I did not make such a comment as was quoted. Do you have other witnesses? I don't mind blood and gore (except vomit), but I didn't like the perpetual tension and the overall culture of the OR. Let the record stand corrected. But let me not distract from another brilliant post. Bravo!

[Mitch Levenberg]

you love the smell of lochia in the morning! really good piece. I wonder if maybe people should just stop having babies. They really don't smell much better after birth either, way into their twenties,do they? And then they get old and really smell bad all over again.

[Mitch Levenberg]

And Adriel, remember,you're mother is always right no matter what she says.

[Dr. Judith Weinstock]

I got plenty o' nothing'. I got lochia in the morning and vernix at night. Ohhh.... And Mitch we try to smell the children as little as possible . That's why we have Curly and Dante.

[Joan Erskine]

Wow! It's a wonder that anyone is still birthing babies.

[Caroline Hagood]

This is a fascinating behind-the-scenes look at delivery.

[Irene Gunther Weinstock]

Interesting piece, Judi. I learned more about childbirth than I did while giving birth to three babies! Which is probably just as well! Too bad that (practically speaking) an obstetrician's lot is not a happy one.

[Sistasasy]

this is so much more than a blog on a single profession
i learned in my memoir writing class that when you take your life, as unique and bizarre as it might be, and convey it in intimate detail, you reach everyone
that is true because the common thread of mankind is emotion
regret, love, shame, happiness are what any elaborate or simple human story are reduced to
and that is why a former black panther can love a brooklyn gynecologist ; )
this well written blog speaks to us all
i am introduced to concepts in this that i am pleased to know about
i also want the public to understand how finances impact the health care practitioner
and how medical access is determined by bureaucracy and the other factors you enumerate
this is another fine example of how you make yourself and your profession more accessible in a country that struggles with the contraction of medical services in certain much needed demographics
THANK YOU & HAPPY HAPPY NEW YEAR

[Dr. Judith Weinstock]

Sista - Thank you for your comments. I think the tie-in between finances and medical delivery just can't be stressed enough. There are still trial lawyers and legislators writing in to the New York Times saying there is no such thing as a malpractice crisis. Maybe they will change their minds when their daughters can't afford a private Ob/Gyn and they don't like the neighborhood clinic or can't find a clinic in the neighborhood, due to decreased funding.