With only a year left in her training as an obstetrician-gynecologist, Dr. Shahrzade Tabibi has no regrets about entering a field that some veterans say is being ravaged by the cost of malpractice insurance.
"It might sound corny, but being the first person in the world to hold a little new baby is pretty incredible and a privilege I hope I deserve," said Tabibi, a fourth-year resident at the University of Maryland Medical Center.
At 28, Tabibi is also a realist. With premiums for doctors who deliver babies surpassing $100,000 a year in many areas, Tabibi predicted that simple economics will force her to abandon obstetrics within a decade. Then she'll concentrate on gynecology - a choice many older physicians are making.
But Tabibi, a Massachusetts resident who attended the UM medical school, is at least giving obstetrics a chance. Across the country, leaders of a specialty that once had great romantic appeal are alarmed because young doctors are increasingly reluctant to do the same.
Since 1996, graduates of U.S. medical schools who enter training programs in obstetrics and gynecology have dropped 23 percent - from 968 to 743.
Although they insist it hasn't happened yet, many veterans worry about an ultimate decline in the quality of doctors competing for training slots in obstetrics.
"Nationally, we certainly are concerned about quality," said Dr. Jessica Bienstock, who runs the OB/GYN training program at Johns Hopkins Hospital. "If we're seeing fewer people going into the specialty, then we do need to start worrying about the quality of people who do go into the field."
The trend shows up in the numbers at the University of Maryland and the Johns Hopkins School of Medicine, each of which once sent up to a half-dozen graduates into obstetrics residencies every year.
At Hopkins, three students in a graduating class of 115 chose OB/GYN residencies last spring, and only one did so a year earlier. At Maryland, one student out of a class of 150 entered an obstetrics-gynecology program this year. None did last year.
"People don't want to be in the delivery room - that's where the malpractice is," said Dr. Jack Gladstein, associate dean of students at the University of Maryland School of Medicine. "Any time a baby comes out bad, the gynecologist gets sued."
Gladstein isn't sure how much importance to place in the past two years, because he has seen the numbers fluctuate between one and six in earlier classes.
But this year, just two-thirds of new residencies in obstetrics and gynecology nationwide were filled by graduates of U.S. medical schools - down from 86 percent eight years earlier. The slippage has forced hospitals to look toward graduates of foreign medical institutions.
Malpractice insurance is just one reason for the decline in interest, experts say. Lifestyle and gender roles also are in the equation.
Balancing work and family life seems to play a larger part than ever before in the careers medical students choose. Students who are concerned about family, leisure time and other pleasures are less eager to put up with the demands of a residency that requires sleepless nights on labor and delivery wards.
"You can schedule your office visits and gynecological surgery, but you can't schedule when the baby's coming out most of the time," Gladstein said.
Dr. Mina Scott, a second-year resident in family medicine at the University of Maryland, said she considered an OB/GYN program but ruled it out, chiefly because the demands on her time would make it difficult to raise a family.
"I love delivering - it's a magical time in a woman's life," said Scott. "Part of me would have been great at it. The other part would have been unhappy with the lack of family time - which is really important."
Another issue: Over the past decade, male students have increasingly viewed the specialty as virtually off-limits to their gender. This coincides with rising consciousness about women's health issues. More female doctors have gone into the field, and many patients prefer them.
But most discussions about changes in obstetrics begin with economics. The Mutual Liability Insurance Society of Maryland, which insures 80 percent of the state's doctors, plans to increase premiums for obstetrician-gynecologists to $160,130 next year, up from $115,919 this year.
In this regard, the specialty leads all others. Neurosurgeons pay the next highest premiums - $87,860 this year and $121,464 next year.
On the other side, OB/GYN specialists are well-compensated by any measure - in the East, they averaged $204,000 in compensation after expenses in 2002, says the Medical Group Management Association. But they also leave medical schools with average debts of $120,000.
Dr. Marc Lowen, director of Sinai Hospital's residency program in obstetrics and gynecology, said he doesn't discuss economics or malpractice with young doctors.
"I think that if they've made decisions to go into women's health care they think it's very rewarding," he said.
Lowen agreed that rising premiums are driving away talented students. They know that fees from the first 25 to 30 babies they deliver every year could go toward insurance. "It's a huge overhead if you're doing 100 deliveries a year," he said.
Lowen said he's also worried that students who might choose OB/GYN are being scared away by teachers who tell stories about how bad their own lives are.
"They hear disgruntled 45- to 50-year-old OB/GYNs who moan about the specialty - the long hours, the low reimbursements," said Lowen. "And the threat of malpractice scares the daylights out of the young people."
Trying to address issue
Nationally, the American College of Obstetricians and Gynecologists is trying to address the problem on many fronts. One panel is working with medical schools to identify "career mentors" who would promote the specialty, start clubs for prospective OB/GYNs and conduct discussions with residents and local practitioners.
Dr. Douglas Laube, head of the OB/GYN residency at the University of Wisconsin and chairman of the national panel, said medical school rotations should expose students to the more positive aspects of the profession. Students, for instance, should spend more time in community practices and less on gynecological cancer services, where he says they spend a disproportionate amount of time.
Students should also understand that the malpractice problem is not uniform across the nation, he said. As onerous as premiums can be for specialists in about 15 states - notably Pennsylvania, Ohio, Nevada and Mississippi - there are many other states where premiums are much lower. In Wisconsin, which has instituted tough tort reforms, premiums average $45,000 to $50,000, he said.
Appealing to male students is also a priority. "Men have felt they were unwelcome in the past seven to eight years," Laube said.
Some doctors hope the field will regain popularity in several years, as graduating students realize they're suddenly in demand. They might also hear about the emotional rewards from young doctors who made the choice before them.
Making a choice
Four years ago, Tabibi wrestled with a choice between obstetrics-gynecology or surgery. She chose the former when she realized that it would not only give her time in the operating room, but also allow her to serve women as they experience the joys and problems of different stages in their lives.
"I just like connecting with women, reaching out to women and helping them understand how to take care of themselves," Tabibi said.
Dr. Jennifer Coles, who is training in OB/GYN at Sinai, said lifestyle issues loom large for her because, at 35 and married, she still plans to begin a family.
"Yet as much as I tried to talk myself out of it, and I knew there were difficulties, I also knew this was the right thing for me," she said. "I like taking care of women and keeping them healthy through their reproductive and post-reproductive years."