The Secret Sauce: A Q&A with Dr. Steven Bloom
By Daniel Oppenheimer
Editor, Texas Health Journal
The UT Southwestern Department of Obstetrics and Gynecology is really big. In 2017, a total of 14,362 women delivered babies at two of the primary hospitals under UT Southwestern’s umbrella of care: William P. Clements Jr. University Hospital and Parkland Hospital. That adds up to about 1 out of every 28 new Texans and 1 out of every 275 new Americans. The Department also has the largest obstetrics and gynecology training program in the country, with 72 residents, or about 1 out of every 70 new obstetrician gynecologists in the United States.
It’s not just a big department. It’s an exceptional one. The residency program has ranked in the top 10 (out of more than 240 programs) in the United States every year since the standard rankings have been published. Dallas County, for which UT Southwestern delivers about 1 out of every 3 babies, has among the lowest rates of preterm birth in the state, along with low rates of non-medically indicated elective cesarean delivery, non-medically indicated elective induction of labor, and infant mortality.
“We work incredibly hard, and strategically, to improve outcomes for our mothers and babies,” says Dr. Steven Bloom, chair of the department.
Texas Health Journal recently spoke to Bloom about how to build and maintain a top-flight program, about the persistent mystery of preterm birth, and about his own experience in the field.
What’s the secret sauce? Why are deliveries at UT Southwestern hospitals so safe?
We work incredibly hard, and strategically, to improve outcomes for our mothers and babies. There is good evidence that the work we are doing is contributing to good outcomes. For something like preterm birth, though, we are only beginning to understand why it happens at all, and what kinds of interventions might help prevent it.
There is no secret sauce, but there is a culture of ensuring timely access to care, practicing evidence-based medicine, conducting research that contributes new knowledge to that evidence base, regularly measuring the quality of our performance, iterating our care in light of the findings, and integrating all of that into our education and training.
Can you elaborate on that culture? What does it look like on the ground?
As a faculty, we have created standard practice protocols for how we care for this huge number of women under our care. If you take 100 of our faculty, they don’t have 100 different ways of deciding, for instance, how they are going to manage a pregnancy complication such as preeclampsia. They are autonomous and are going to apply their best judgement to each situation, but within a framework of practice guidelines and protocols. That is very different from allowing people to do whatever the heck they want, practicing in an erratic and undisciplined way.
We also measure key outcomes for all our patients and employ a biostatistician to make sense of the data. We are constantly monitoring what is happening and feeding that information back into our practices. And we are doing original research to improve care, which can ultimately change the guidelines and protocols as well.
It also helps that we are training so many medical students and residents. Our faculty aren’t just doing the work of caring for mothers and babies. They’re also teaching students and residents how to provide that care. They have to have logical, well thought out explanations for the care they’re providing. Why are we doing what we are doing? Why are you not inducing this patient, but you are inducing that one? Why are you inducing labor on such and such a date as opposed to a week later or earlier? Students are asking questions all the time, and we have to come up with good answers that are grounded in evidence, and that correspond to good outcomes. It helps to keep everyone on their game.
You guys are a really big department. You have a lot of doctors, you deliver a lot of babies, you train a lot of residents. Are there benefits to the size?
Absolutely. I’ll give you one example. As a result of our scale, our practice is the same whether it’s 3 in the afternoon or 3 in the morning. We’re fully staffed 24 hours a day, with a full contingent of OBs, anesthesiologists, pediatricians, nurses, and staff. There is no pressure to get a patient delivered by a certain time, because someone is scheduled to leave. We don’t need to call doctors from home or from another facility to make sure that high quality care is provided.
We also have the resources to do sophisticated analyses of our practices and outcomes, and the data to find meaningful trends or problems. A smaller group practice, or a smaller hospital, may not have the quantity of data readily available to be able to measure whether their practices are producing statistically significant differences in outcomes.
Then, of course, there the benefits of practicing in a world class clinical and research institution. We have leading specialists not just in obstetrics and gynecology, but in other departments that intersect with our work, like pediatrics and anesthesiology. And on the basic science front, members of our faculty have received almost continuous funding from the NIH for approximately 30 years as they attempt to discover the mechanisms of what triggers normal, and premature, human labor. In 2017, our department ranked 7th nationally in total NIH grant funding.
Tell me more about your department's work in studying preterm birth. What are we trying to understand?
Unfortunately, there is a lot that we still don’t know. In fact, we don’t understand a great deal about why women go into labor normally, let alone all the reasons why they go into labor preterm. That’s a gap in understanding that we have to fill, because preterm birth is associated with so many adverse outcomes.
We know that our rates of preterm delivery are lower than nationally reported data, and that’s a good thing, but even within our own system we don’t fully understood why that is the case. We have some hypotheses. For instance, in addition to our clinical program at UT Southwestern, our faculty also manage the obstetrics and gynecology program at Parkland Hospital, which is where our residents train. Of the 12,000 women who have a baby there every year, 98% receive prenatal care in the Parkland system. It is a very well organized, mature system.
We have compared the rates of prematurity of that 98% who do receive care with us to the 2% who did not receive prenatal care at Parkland, and the results are stunning. The women who didn’t get prenatal care in our system had much greater rates of preterm birth. But that leaves open the question: What is it about the prenatal care system that leads to those outcomes? What is actually happening, as a result of these visits, that is making preterm birth less likely? These are questions we are very interested in.
What is it?
We don’t fully know. We are not doing anything magical. Because Parkland is the safety net hospital for Dallas County, we focus intensively on education, on access, on creating a venue for each woman that is relevant to what she is experiencing to try and that reduces the strain that often comes with navigating a health care system. It makes intuitive sense to assume that that reduces the stress on her and on her pregnancy. That is a good thing on its own terms, and probably a good thing medically, but from a scientific perspective we don’t fully understand.
We know some things, but not as much as you’d think. We know that certain behaviors and practices can increase or decrease the risk of prematurity. It is important not to smoke or drink. It is good to exercise and eat healthy. Some infections increase the risk. A history of prior preterm birth increases the risk. But there are always cases of women who exhibit none of the risk factors, who have done the best they can to take care of themselves and their baby, and still have problems. And despite tons of scientific effort, the actual mechanism whereby a woman goes into labor prematurely, or doesn’t, remains elusive.
Let me end by asking a question about your residency program? What are you looking for in a resident?
Good question. It’s a very competitive program, and when it comes down to the final decisions it’s hard to make distinctions. They are all amazing these days. Their personal accomplishments and test scores are so stunning. I wouldn’t have made it myself, if I had to compete against them. The truth is it often comes down to intangibles. We want people who are going to work well on a team. People who are genuinely interested in serving our population of patients. We are looking for people who embrace being a learner and a professional, to getting better and growing as a professional. And we do our best to find good fits. Are they a good fit for us, and are we a good fit for them?