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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  1. grass
    Posted March 29, 2007 at 7:07 pm | Permalink

    Crazy – my midwife appointments (I’m in B.C.), 2 so far, are about an hour. That’s one of the main reasons I chose midwifery care. It’s give us the chance to talk about the pros and cons of all the different things, like the quad screens etc. Anyway, 25 minutes sounds pretty darn fast to me! I’m sure the extra time is very much appreciated by your clients.

  2. The Student
    Posted March 29, 2007 at 7:28 pm | Permalink

    I’m sure it’s very much appreciated too. In fact, I have a feeling a lot of the women I see repeatedly for their prenatal visits really enjoy their visits with me, for that very reason.

    Midwifery serves many different purposes and roles. For many midwives, this means private practice and offering a vibrant, viable birth alternative to women, which is indeed one of the great things about midwifery, and one of the reasons many women seek out midwifery care. But in New York, many of the midwifery positions available are in large clinics in hospital settings (although of course birth centers and private practice and homebirth exists here too). In the hospitals, midwives serve a different role: not so much to offer a viable birth alternative to women who specifically seek out midwifery care (although that sort of happens, just by virtue of having midwives there), but to give excellent, low-risk care to many of the low risk, underserved, immigrant populations which exist in this city. None of the women in this population really seek out midwives specifically, they’re not really looking for alternative birth practices, but for many of them, midwifery care makes a lot of sense, and for many of them, they’re very accepting of midwifery care because they come from countries where midwifery care (and natural birth!) is the norm. Almost all of our clients are on medicaid, very few of them speak English, and I’m sure many of them are not here legally, but I think midwifery serves a very good, appropriate and needed role for them, and they do get excellent (if rushed) care (and I think they certainly get more time and better care from the midwives than from many of the other clinic options which might be available to them).

    The only drawback to this, of course, is that it’s clinic care: high volume, and fast visits.

    Sounds like you’ve got some lovely midwives in B.C. Enjoy your delicious hour long visits! I hope that I too, someday, might be able to spend that much time to spend with my clients.

  3. k
    Posted March 29, 2007 at 7:40 pm | Permalink

    Yup, here in MB we have hour long slots too. Granted some are cut short, or just are shorter by nature.
    Hellooooo! You can have the best of both worlds up here! HINT HINT HINT!!!!
    Work in a “clinic” with three other midwives then do visits both at the office, and at homes!!! And best of all, you have to allot a certain amount of “clients” for homebirths. Yuppers… no joke, have to take clients for homebirths, not just at the hospitals!
    ahem…. I believe I’m going to start begging soon! 🙂
    You sound a lot more relaxed in general, from the last post. Time is time, women are priceless.
    Thank you for seeing that for what it is!

  4. The Student
    Posted March 29, 2007 at 10:05 pm | Permalink

    I can’t move to Canada, my dear, because then I would have to go to school all over again, and that is NOT going to be happening for quite some time. It’s already bad enough that my beloved boy is British, and there’s a very good chance that we’ll be moving to England in a few years. Unfortunately, I already tried once to have my nursing license transferred over to England so that I could work as a nurse in London, and they wouldn’t accept my qualifications because I had done an accelerrated nursing program and didn’t have enough clinical hours to meet their standards. So, because I’m not qualified as a nurse in england already, I will have to do a combined nursing AND midwifery course of study all over again in order to qualify as a midwife over there, which is another 3 years of school!! Ugh! I can’t even fathom it. I told my beloved boy that he has to let me be a midwife here in the States for at least 2 years, just to get a chance to savor the fact that I’m actually a *midwife*, before we even talk about moving back to England. The thought is not appealing, either in England or Canada. 😉 I wish they made it easier for us to transfer our degrees between countries!!!

  5. k
    Posted March 30, 2007 at 11:40 am | Permalink

    ahem… we have the PLEA’s up here.
    Most of our midwives have done their studies South of the boarder either in person or through correspondence! I know that all three that I worked with did. The fourth was an L&D nurse and decided to head over to midwifery on her own! So…
    No more school. Only studying…
    Well, the beloved boy may not be so crazy about Canada… but at least we are part of the Commonwealth? Right beloved boy? Not all Canadians are awful!:-)
    And from what I’m reading… The big beautiful country across the puddle is getting desperate too! You may not need to do so much as an equivalent to a plea over there. We lost one fairly new midwife to love and England at Christmas. She is up and practicing as I type… well maybe, it is night time over there after all!

  6. k
    Posted March 30, 2007 at 11:41 am | Permalink

    Gee, can I sell Canadian midwifery or what?
    sorry. I’ll shut up now!

  7. Posted April 2, 2007 at 8:04 am | Permalink

    I had concurrent care for my first pregnancy–First off I had my home birth CPM who came to my house on the regular prenatal schedule, spent at least an hour with me–almost all talking and answering questions while I drank tea–then onto the measuring, pee evaluation, occassional hemoglobin testing. The best part is that she explained it all to me and taught me how to read the urine strips and explained all the notes she took and her shorthand. I truly felt empowered to understand what was going on.

    Second I went into the OB clinic to see my CNM every 6-8 weeks or so where I could get any lab tests I wanted, sonogram, etc. (most of which I declined.) At the office I waited in the waiting room for 20-60 minutes, my CNM had a reputation for being slow which meant I usually got to talk to her for 20 minutes or so–maybe 30. I always felt respected, listened to, at ease, even unhurried, and I really liked all the people there. I knew that if I ended up needing to go the hospital I would be in good hands with a person I trusted.

    That said, I left the clinic feeling like I’d been through a whirlwind and inevitably remembered questions I’d meant to ask after the fact. I much preferred the unhurried, detailed, talk as much as I needed to visits at home with my CPM. It’s a real shame more women can’t get that kind of real personal, unhurried care. As a patient, I know when a health care practitioner wants me to get to the point–even when they’re always willing to listen and answer questions, there’s a part of their brain hoping that this is the last one.

    The best ones hide it better and work on giving off a sense of “I have all the time in the world.” I wish you all the best luck if you stay in a hurried, tight, clinical setting. And yes, listening to women is what midwifery is all about.

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