Doctors Drop Out as Baby Business Gets Too High-Risk

In the seven years he practiced obstetrics, Paul Bluestein really liked delivering babies.

And, in contrast to most of his peers who were spending their days dealing with sick or dying people, Bluestein also enjoyed working with the healthy young women who came to him for help during their pregnancies.

But two years ago--after spending four years in medical school, another five in residency preparing for what was supposed to be a lifelong career and the years in practice--Bluestein, then 38, quit obstetrics for an administrative job with an Orange health care firm.

His reasons had little to do with the joy of bringing babies into the world and everything to do with an increasingly emotional national issue: malpractice.

Sued Twice in Brief Career

In his brief career as an obstetrician-gynecologist, Bluestein was sued twice. He settled the second suit for $60,000. The first, involving a baby with a birth defect, dragged on for seven years before Bluestein was dismissed as a plaintiff.

Both suits taught Bluestein to practice medicine in a manner he disliked--”defensively.”

Also, he felt “blind-sided” by that first suit--by a patient he thought had liked and trusted him. “You think: ‘If that patient could sue me, then potentially anybody could.’ ”

Bluestein is one of a growing number of doctors in Orange County and around the nation who have grown disenchanted with obstetrics because of twin pressures--the threat of malpractice suits and, with that, the rapidly escalating cost of malpractice insurance.

A recent survey by the Orange County Obstetrics and Gynecological Society gave evidence of the depth of the problem here.

Concerned about the twin pressures, 29% of Orange County gynecologists polled recently either have stopped delivering babies or are seriously considering giving up obstetrics.

Dr. Allan E. David, an Irvine obstetrician who is president of the society, said he was surprised at the strong interest in the survey--75% of his 179 members participated--as well as the number of doctors who were not just grumbling about the malpractice threat but “acting on their concern.”

Rising patient expectations have led to more lawsuits against obstetricians, David noted.

“In obstetrics, every woman starts with a premise that she’s going to have a perfect baby,” he said. “The problem is, if you don’t get that good result, everyone assumes it’s (the doctor’s) fault.”

The poll showed that 19 of 135 doctors, or 14% of those responding, had stopped practicing obstetrics in the last five years because of the threat of lawsuits and the high cost of malpractice insurance--now more than $50,000 a year in Southern California.

A Tension-Ridden Specialty

“OB has become a high-risk, tension-ridden, uptight specialty,” wrote one doctor who had quit in a note scribbled at the end of the anonymous survey form. “Every decision you make is colored by the threat of a major liability judgment hanging over your head.”

Another 20 doctors of 110 still practicing obstetrics--or 18% of those surveyed--said they seriously were considering curtailing obstetrics because of concerns about malpractice.

Six other doctors reported that they had stopped practicing obstetrics for reasons other than the malpractice threat--such as ill health or advanced age. The society’s 179 obstetricians and gynecologists represent about half those now practicing in Orange County, David said.

The Orange County survey parallels a just-published national survey on the same subject. On March 2, the 26,000-member American College of Obstetricians and Gynecologists in Washington released a poll of 2,000 of its members, which showed that 12% had stopped delivering babies.

In New York, where malpractice premiums average $52,000 a year, that figure was 8.3%, the survey showed.

In California, where the average malpractice premium was $29,683, 8.7% of the doctors surveyed had dropped obstetrics.

But in Florida, where malpractice premiums range from $76,000 to $152,000 a year, 25% of those polled indicated that they had stopped delivering babies, according to Penny Rutledge, an attorney in the American College of Obstetricians and Gynecologists’ department of professional liability.

In another era, older doctors who grew tired of delivering babies at all hours of the night would ease into retirement by limiting their practice to gynecology, David and other doctors said.

Younger Doctors Quit

But now, because of malpractice concerns, “younger and younger doctors” are giving up obstetrics, and many of those who continue in the specialty report that they will no longer accept high-risk patients, Rutledge said.

She noted that 75% of the obstetricians surveyed said they had been sued at least once. Such suits create an adversary relationship between obstetricians and their patients, Rutledge said, noting, “Whenever a new patient walks in, you don’t know if that’s another lawsuit.”

The drop-out rate among obstetricians can mean that pregnant women in rural areas sometimes have trouble finding a doctor to care for them, Rutledge said. Some of these women have to travel up to 100 miles to find a doctor who will give them prenatal care, Rutledge and other malpractice experts said.

Availability Diminishes

In California, most pregnant women can still find an obstetrician, although those on MediCal often have difficulty getting care, said Charlotte Newhart, a consultant on maternal and child health for the California Medical Assn.

But, Newhart warned, “if the trend continues” and more doctors give up obstetrics, “I anticipate an access problem for all women.”

Despite the number of Orange County obstetricians who have or are considering dropping their practice, doctors say there is as yet no apparent shortage. In time, however, that may not be true for the indigent.

“It is true that the cost of malpractice has had an impact, but we have plenty of obstetricians in Orange County to care for patients,” said Dr. Kirk A. Keegan, associate professor of obstetrics and gynecology at UC Irvine and a specialist in high-risk patients.

Indigent Have Problems

“I do not think that is an issue for people to be concerned about except in the area of people who are on state assistance,” Keegan added.

Dr. David agreed. “I would say right now there is adequate care available. Whether that will change in the future, I don’t know. There may not be adequate care for the indigent,” he agreed.

Keegan said escalating malpractice-insurance costs are not the only reason that fewer doctors are seeing patients on Medi-Cal or those in the county’s Indigent Medical Services program. “It has more to do with reimbursement levels (from the state or county),” he explained.

Still, Keegan added, when obstetricians have “a constant concern over litigation, it really poses a problem when you can’t meet your expenses because you are caring for patients who cannot provide revenue to meet those expenses.”

Stiff Premiums

Obstetricians in Southern California now pay higher premiums for malpractice insurance than any other medical specialists.

The cost for a typical policy that pays up to $1 million for a single incident or $3 million for the year is $50,804, said Howard Williams, vice president of Southern California Physicians Insurance, a doctor-owned firm in Orange that is the largest insurer of physicians in the state.

By contrast, Williams said, a neurosurgeon pays $42,852, a gynecologist who doesn’t deliver babies or perform abortions pays $36,336, a cardiologist pays $20,256 and, at the bottom of the scale, an allergist pays only $5,192.

The reason for the substantial differential, several obstetricians and insurance industry officials explained, is that an obstetrician is dealing with two patients--the mother and her unborn baby. If the baby is born with a defect, that child may have to live with an impairment for life.

May Pay a Lifetime

And if the defect was caused by a doctor’s mistake, that doctor who erred--or more likely, his insurance company--may have to pay damages to account for the child’s handicap over a lifetime.

Also, industry officials and doctors noted, because of the increasing size of jury awards for malpractice, the premiums for obstetricians have increased steadily every year. In the last three years, for instance, Williams of Southern California Physicians Insurance noted that his firm’s premiums for Ob-Gyns rose 70%--up from $29,736 a year in 1984 to $50,804.

Pregnant women feel the impact in the form of higher fees, which David said range from about $1,250 to $2,000 for a normal pregnancy and delivery in Orange County.

“It’s clear that the physicians are going to pass that cost (of malpractice insurance increases) on to the patient,” UCI’s Keegan said. “That’s just like any other business expense.”

Doctors Offer Comments

In the Orange County survey, several obstetricians said they had stopped taking high-risk patients or reduced the number of deliveries they handled because of malpractice concerns.

A sampling of their comments:

From a doctor still practicing obstetrics: “I would quit OB if I could afford to lose the income. The liability problem is far out of hand.”

From one who has quit: “It’s very hard to work night and day. The hazard of economic ruin from a single malpractice suit makes it untenable.”

Another complained: “Obstetrical practice is not a practice of medicine anymore. It is a gamble. This is a conspiracy of the legal system against people and doctors.”

Jumped at Job Offer

The survey was anonymous, but several Orange County doctors who recently quit delivering babies agreed to discuss why they had done so.

Bluestein, for instance, said he grew deeply discouraged with obstetrics because of worry over the threat of another suit. So when he was offered another job--as regional medical director for Corporate Health Strategies, an Orange health-care firm--he jumped at the chance.

Bluestein hadn’t imagined himself as an administrator. He had liked dealing with expectant mothers because “you see the results of your work very quickly and the end of the process, most often, is a happy one.”

But in the seven years over which the first malpractice suit lingered, Bluestein said, he stopped enjoying his work. Instead, he became “gun shy.”

‘You Become Less Open’

“Rather than being a friend to a patient, you become a little less open, a little less exposed,” he said.

“At a time when my fear was not so great, I would try to put the patient’s mind at ease by not bringing up all the possible things that could happen if something was going to be bad. . . . I would say, ‘I’m sure everything will be fine.’

“But that’s an unacceptable answer right now. Not only do you not wait for the patient to ask, you have to say, ‘One of the things that may happen is you may die in anesthesia,’ or, ‘If you have a Caesarean delivery, you may bleed to death.’ ”

Because of these concerns, Bluestein said he has no regrets about quitting obstetrics. Now, he said, he enjoys dealing with national and local health-care issues in his present job and also, occasionally, acting as a malpractice consultant. (At a malpractice seminar for doctors in April, he will advise his colleagues on how to give a deposition.)

Learned From Friend

Another former Ob-Gyn, Dr. Gerald Podolak, 56, who practices in Tustin, gave up obstetrics last year for a practice that consists now of gynecology, with a sub-specialty in infertility.

Podolak said he did so after watching a friend and fellow obstetrician lose a $2.5-million malpractice suit, file for bankruptcy, lose his house and move out of Orange County in search of another job.

“I miss delivering babies,” he said. “I miss the ability to participate in the development of a family. That’s the reason I went into obstetrics in the first place.”

But after his friend’s experience, Podolak “became alarmed” that he might be sued. In 20 years of practice, that had not happened. But “it’s sort of like waiting for the other shoe to drop,” he said.

Difficult to Justify

“Something can happen beyond a doctor’s control that would result in a damaged baby . . . but you drag a damaged baby into a courtroom--and it’s very difficult to explain it away.”

Actually, Podolak pointed out, there were two threats if he had continued in obstetrics: “The threat of being sued and the threat of having a jury judgment that would exceed the available (malpractice) coverage.”

Podolak said he explored the possibility of increasing his insurance from the standard $1 million-$3 million coverage to $2 million-$4 million coverage but discovered that by doing so, his insurance premiums would increase from $52,000 a year to $86,000.

“I couldn’t increase my obstetrical fees to cover that kind of cost,” he said, “so I was stuck.” He decided to drop obstetrics from his practice.

Podolak said that he has suffered “an economic loss” since he curtailed his practice but that he was forced to do it. “The threat (of being sued) was emotionally too much to bear.”

Since he has made the change, Podolak said other obstetricians have been interested in his decision and they are always sympathetic.

They usually have one other reaction, he said: “They’re a little jealous.”