Friday, June 21, 2024

BGH obstetrics closure is heartbreaking to see

by DR. DEB OWEN Contributing Writer
| March 19, 2023 1:00 AM

Like most breaking news in Bonner County, I first heard about the closure of the obstetrics service at Bonner General Health through the “Sandpoint grapevine." News spreads fast in a small town. Especially when you are an obstetrician who lives in that small town.

Part of me was heartbroken. Even though I no longer practice in Sandpoint, or in Idaho at all, I still live here and I felt grief for the staff of Sandpoint Women’s Health and the Bonner General nurses who have served the women of Bonner and Boundary counties so well for so long. I cherish the memories of the years I spent helping to build the practice, developing relationships with my patients and their families and delivering the next generation of Sandpoint natives.

That was my emotional reaction. My more practical side was not surprised or shocked at all. Rural obstetrics for years has been a house of cards. Rural units nationwide, especially in the Midwest, have been closing in droves over recent years. There is a national OBGYN shortage that has been worsening ever since I finished training 33 years ago - and it has escalated dramatically in the past 10 years.

Newly minted OBGYNs are fought over by huge hospital systems willing to pay just about anything to recruit them and have their pick of dozens of jobs fresh out of residency. Experienced OBGYNs wishing to relocate are hounded by headhunters every day wanting to place them. Even older docs like me are inundated with requests by locums (temporary staffing ) agencies to come and help fill in the gaps until a full-time doctor can be recruited. Every day I get at least five texts or calls from recruiters in Washington, Idaho, Montana, and Wyoming who want me to come help rural hospitals fill their coverage gaps. Most OBGYN residencies are located in large urban areas. There are none in Idaho. Most OBGYN residents these days are women — they have employed partners or spouses and have little desire to leave the general location in which they trained to live in rural America.

According to the UW Medical Workforce data from 2021, there are roughly 178 OBGYNs practicing in the entire state of Idaho — 140 of them are in urban areas. The mean age of a physician in Idaho is 50-55 years of age. This is not good news. Nevertheless, a few special places like Sandpoint have always managed to recruit OBGYNs with enough time and patience. A thriving and varied medical community, arts and culture, unparalleled recreation and scenery, and easy access to the natural world have their attractions.

Rural practice is hard. I have practiced in both rural and urban settings for 33 years and I will tell you rural practice is by far the most challenging. You have fewer resources, more night call burden, less backup and access to specialists to help you with challenging patients. You also struggle to pay the bills. Rural jobs usually don’t come with Blue Cross. Working people struggle to pay what they can or forego care. Pregnancy tends to be covered by Medicaid in Idaho. But even Medicaid doesn’t cover expenses in many cases in a unit that is required to be staffed 24/7/365 by physicians, nurses, OR crews, anesthesia, and sonography for an emergency case that might walk in at any moment.

In obstetrics, there frequently isn’t time to arrange transport to a higher level of care if labor goes wrong. Women birthing at home, or in a birthing center are brought in when things aren’t going well and you have to be prepared to help them even though they haven’t chosen you for OB care. And you can’t transport someone in active labor. So you have to be prepared for anything at any time. Obstetricians on call have to be within 15-30 minutes of the hospital at all times. And all of that costs money. A lot of money. The loss of one physician can make the night call burden unsupportable for the remaining doctors. In the past hiring someone like me to help cover calls while recruiting a replacement wasn’t that hard. I was honored to help out on weekends at SWH a couple of years ago when they were looking for a new physician even though I have a full-time job on a high-risk OB unit in Spokane.

Unfortunately, with the passage of Idaho’s “trigger laws” after the fall of Roe v. Wade I believe that recruitment of new OBGYN physicians to Idaho will be almost impossible going forward. Idaho now has the most restrictive abortion laws in the country, criminalizing care for women with high-risk, nonviable pregnancies and has no exception for the life or health of the mother under any circumstances except for ectopic pregnancy. And that had to go to the Idaho Supreme Court to be considered allowable.

We aren’t talking about women who want to voluntarily end their pregnancies. We aren’t talking about doctors who want to provide elective abortions. That hasn’t been the case in Idaho for a long time. There was only one clinic in Boise, otherwise, you had to go out of state. But life-saving care for women with pre-viable (too early to be able to survive outside the womb) pregnancies complicated by infection, hemorrhage, ruptured membranes, life-threatening heart disease, stroke, severe pre-eclampsia, impending miscarriage, and lethal fetal anomalies was never illegal or a felony. With no hope of a surviving baby saving the mother’s life and preventing permanent health damage was considered paramount. Now it is a felony.

And also a basis for civil lawsuits that can be filed by any number of the patient’s relatives. “But that isn’t what we meant!“ is the refrain I hear (usually privately) from my friends with more conservative political leanings. But that is what the Legislature enacted into law, and has now been upheld as Constitutional by the Idaho Supreme Court. Even the most pro-life patients will rarely choose to sacrifice their lives and leave their other children orphans for the sake of a fetus that can’t survive, or risk loss of reproductive capacity and future pregnancy. Yet that is exactly what our lawmakers now expect from their constituents. Or at least those of their constituents that do not have the means to travel out of state.

The fallout from this is that OBGYN physicians are quietly leaving the state. Most physicians don’t go into medicine because they want to have frequent contact with the legal profession. It’s easier to relocate than to live in fear or have to live with yourself when you are forbidden to use your skills and training to save or help a patient with a severely compromised pregnancy. Boise has lost two specialists in maternal fetal medicine (high-risk pregnancy specialists) because of this. And there are no replacements to be found.

OBGYN also has a grapevine — there aren’t that many of us after all — as I monitor conversations on the grapevine several things have become apparent. New graduates are wary of accepting a job in states with the most restrictive laws — like Idaho and Texas. And now Tennessee and Kentucky. There are so many other jobs out there in other states. Most of these new graduates do not desire to become providers of elective abortions. But they do not want to face incarceration for terminating pregnancies that threaten women’s health and lives either. I personally know of several OBGYNs who have either left Idaho or are actively seeking jobs in other states with plans to move as soon as new employment is finalized, but haven’t yet announced their departure. It can take up to a year to negotiate a new position, acquire a state license, and get credentialed with insurance companies and hospitals. Physicians don’t tend to publicly announce plans to leave until new employment has been secured and underway. I believe we have only just started to see the effects of these new laws.

Many physicians were waiting for the Idaho Supreme Court decision hoping that there would be some exceptions allowed. With the recent decision upholding these extreme laws OB physicians are quietly evaluating their options. The losers? Women in these communities and their families. Doctors don’t seem to have to power to impact this process, but they can vote with their feet — and leave. Citizens don’t always have this option, especially in the middle of a pregnancy crisis. But they do have power at the ballot box, should they choose to exercise it.

Dr. Deb Owen is a Bonner County resident who graduated from Duke University of Medicine. Now working at a Spokane hospital, she was a founding partner of Sandpoint Women's Health.