The need for speed

I’ve been under a lot of pressure lately to become much much MUCH faster at my clinic visits. My clinicals are at a very high volume clinic where the midwives (two to three, depending on the schedule) can often see about 35 patients in a day. This means that each midwife, on the days that there are three, has to see at least 10 patients during their 8 hour shift, and on the days where there are only two midwives….well, you sort of hope that a few of the patients won’t show up for their appointment (and in fact, there are often many who don’t come, for various reasons…either they went into labor and delivered already, or something else came up). Prenatal revisits are supposed to take about 15 minutes, and initial prenatal visits are supposed to take about 30 minutes. Add to this the fact that my preceptors are having to supervise me, and follow-up on all of my fundal heights, and be present in the room during all of my pelvics and bimanual exams…and, well…it gets a bit overwhelming at times.

I’ve been trying really hard to go faster, but try as I might, I am still really, REALLY slow. Really slow. A new visit will take me about an hour, and a revisit will take me about half an hour—sometimes 20-25 minutes, on a good day—and yes, I’m timing myself (my preceptors insist on it). Part of the problem is that I’m still very new at this, and there are still many, many visits where I’m presented with a problem or a complaint that I have never encountered before. Sometimes I do have an idea of what to do for the patient, but because I’ve never had to do this before, I always want to run it by my preceptors first to make sure that I have the right plan, or the right dose, or the right medication, which takes time. This happened the other day with a woman who was vomiting 10-12 times a day from her terrible morning sickness. She was eating and drinking okay, able to keep a little bit of it down, and she didn’t look dehydrated (good skin turgor, mucus membranes moist, no ketones in her urine), so I wanted to prescribe rectal compazine for her, to help get the vomiting under control, and then Vitamin B6, but I wasn’t sure if this was the right thing to do. Turns out, my preceptor totally agreed with me, and added some oral Reglan to the mix, but this required a 10 minute consult to work out. Other times, I have no idea what to do for the patient, in which case I need to talk with my preceptors anyway, just to sort of figure out how to wrap my head around the problem. Part of it, as well, is that because I’m new to all of this, I’m also a bit paranoid: I want to be as thorough as possible and I want to do this well, so I always try to cover as much information as possible in each visit and to teach as much as possible in each visit, to make sure that I’m not missing anything, and frankly, 15 minutes is just not enough time to cram in all of the teaching and talking which needs to be had during a revisit. And of course, I’m slow because I really enjoy listening to women, and I have a hard time interrupting them, or rushing them in order to get to the point of the visit. If they ask question after question, I answer question after question. If they have a slew of complaints—their round ligaments hurt, and they have sciatica, and what is this funny rash on their arms, and they keep getting leg cramps—I let them tell me all about it. I try to ask about their mental health: how are they feeling about the baby now? Still ambivalent? Getting excited about the impending birth? Worried about pain management? Maybe I shouldn’t be asking them any questinos, because it usually opens up a can of worms, and I think this is where I lose a lot of time…but I feel like this is important stuff. One of my preceptors told me the other day that I let them talk too much….I think they were saying this jokingly, but honestly, I thought one of the biggest parts of our job was listening to women??

Anyway, I’m slow. I’ve been working with my preceptors to try to find ways to make me faster, such as always approaching the visit the same way, and trying to save time by efficiency and hyper-organization. For example, on a revisit, this is what I do (or try to do), every single time, so that it becomes an efficient routine for me (that’s the theory, anyway): I open the chart, read the problems list page, read the labs page, look up her record in the computer, see if there are any new labs which need to be added to her chart, then I scan through her history and physical quickly, read her last ambulatory care note (if I have time), then call her in and talk to her. First I ask her how she’s feeling, then (when she’s finished talking, which can take awhile, see above), I tell her how many weeks pregnant she is, I tell her the results of her last lab test or sonogram, and then I talk to her about what routine lab tests we need to do today, and why we’re doing them, and what they’re for (GCT, quad screen, CBC and RPR etc.). I ask her if the baby is moving, if she’s had any vaginal bleeding, loss of fluid or contrations, is she taking her prenatal vitamins and iron, and then, up she goes onto the examining table. I measure her fundus, do my Leopold’s, we listen to the baby’s heart beat, and then I get my preceptor and have them come in to double check my findings. If she needs a pelvic or a wet mount or a clean catch, we do that too, and then I have to go look at it under the microscope (always time consuming)…and then prescribe the correct medication for her yeast infection or vaginitis, and order her chest x-ray or urine culture and sensitivity or glucose challenge test. Then, I try to reinforce her teaching, ask her about her diet, go over the tests we’re doing today, as applicable, tell her when her next appointment will be (2 weeks, 4 weeks), and send her on her way. Just typing all of this out has taken me nearly 10 minutes. Sheesh!

It really doesn’t seem possible to me, and yet I know it IS possible, because I see my preceptors doing it all the time. They work under incredible time constraints, and yet, somehow, I feel like they always manage to put the patient at ease, get to the point of the visit, provide excellent and appropriate care, and still make her feel like she was heard. How in the world do you do that??? It defies me!

Anyway, I am twice as slow as where my preceptors think I should be right now, so daily, in the clinic, I always feel like I’m not meeting expectations, or not performing to the level that I am expected to perform at. And, as you might have noticed, I tend to be a high achiever. It really bothers me when I feel like I’m not up to snuff, and has been wreaking a fair amount of havock on my self-confidence lately. I just keep thinking about the fact that pretty soon I’ll be doing this on my own, and how can I, if I can’t even do a 15 minute revisit? How will I survive as a real midwife in the world?

And here’s the other problem: when I go slow, at the pace I need to go at in order to absorb all of the information correctly, and process it, and figure out my plan, and take my time, I do very well. I’m thorough, I generally don’t miss anything, and my preceptors compliment me and tell me that I’m doing well (aside from the speed issue, which they’re always telling me needs to get better). A few times, now, we’ve been timing my visits, and I’m only allowed 5 minutes to go thorugh the chart prior to having the patient come in, and wouldn’t you know it…when I’m really worrying about my timing, and constantly glancing at my watch, and thinking in my head “faster, faster, faster!!!”, I make mistakes, I miss things, I don’t do a good job at anything, and I feel like a failure, all at the same time. And yet, when I go slow, I feel like I’m not meeting expectations, and not progressing, and not at the level I’m supposed to be at….and I feel like a failure, too. It’s just this glorious sense of just not quite being as good as I’m supposed to be at all of this, and it really kind of sucks.

But sometimes I wonder…am I actually not up to snuff, or are my preceptors’ expectations a little unrealistic? Is it possible that maybe I am actually at the pace and level that I should be, at this point in my education? I go back and forth about this a lot.

Of course, there are settings where no midwife is expected to do a 15 minute revisit. Homebirth midiwives and private practice midwives can take a lot longer…maybe even as long as they want. But I don’t think these are the settings I will be practicing in as a new grad. The market for midwives isn’t great right now, and I know I’ll pretty much take any job that is offered to me, and I’m fairly certain that this will be in a hospital setting, where I will be practicing (you guessed it!) in a clinic. Honestly, though, this is the job I want, because I’m certainly not ready for homebirth or private practice right now, and I need the experience and structure. But sadly, in these kind of settings, 15 minute revisits are pretty much the norm. And I really do want to be good at this. I want to be like my preceptors, fast AND good at the same time. And I DO think I’ll get there eventually….but maybe not during my Integration. Just give me a little more time, please.

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