Year One

I have been in midwifery practice for a full year. No longer can I cling to the safety of the label “new grad.”

This year has been one of immense change and learning, both personally and professionally. I started thinking this morning about all the lessons I have learned this year. I began thinking about my current practice and thinking of all the things that I was scared about as a student, and some challenges that I couldn’t even forsee from the shores of studenthood.

This year, I have learned a great many things, and in no particular order, here are some of the most striking lessons:

1) It doesn’t matter what you know if you can’t convey it to patients. Figure out simple analogies and schpeils that help everyone understand what you are trying to say. The more ridiculous and memorable the better. One of my favorites has become “Your vagina is a self cleaning oven. It is very smart. You don’t need any douches or washes to keep yourself clean.” People will not forget that their vagina is a self-cleaning oven. People will forget that you tell them to use non-scented, gentle soap and only a washcloth.

But at the same time, don’t underestimate what people can understand. Take a minute to explain the simple science behind your recommendation and reasoning. Explain the reason that your patient doesn’t need a pap smear this year is not because you don’t have time to do it, but because really amazing, exciting studies have tied the HPV virus to the vast majority of cervical cancers that we see, which is why we can expand the window of time in between paps. (Side note: tell everyone who will listen to you about the HPV vaccine and vaccinate them). Explaining your reasoning and recommendations lets patients be active partners in their health care,  and it is your job as a health care provider to allow women to be not just your patient but your partner in decision making.

2) Pick your battles. Is your patient an ex-heroin user? Maybe let’s leave smoking cessation education to the next visit. Similarly, recognize how difficult it is to change behavior and congratulate patients on these accomplishments. It is a huge accomplishment to quit smoking, and health care providers should tell patients this more often.

3) Face difficult emotional issues head on. Acknowledge that topics like rape, suicidal ideation, grief about an abortion, and addiction and substance abuse are difficult to talk about, but use correct and clear terms. I have found that peeling the lid off these issues is incredibly difficult, but most of the time if you make a simple statement and leave some room, patients will usually guide the conversation in a way that is comfortable for them. Often when I see that someone has marked down “little pleasure or interest in doing things” and “thoughts of self harm” I will simply state, “I was looking over your history form. It looks like there are some difficult things going on, emotionally.” Let the words hang in the air for a minute. Even if it creates a moment of silence. Trust that your patient will lead you to what they need to talk about.

4) Develop your own style, but know how to talk to many different types of people. Everyone needs something different from their health care provider. Many young women feel comfortable talking with me because I am either their age or slightly older and can be viewed as a confidant. Many older women view me with suspicion after a lifetime of seeing young or incompetent or dismissive (or any combination of the three) health care providers. I know I need to win their trust with listening, with carefully constructed responses, and with a gentle but sure touch.

5) Never stop learning from other providers, either from those you work with or from reading about how others practice and figure out a way to incorporate their style into yours if you like something you see. I recently learned how to do a paracervical block from one of the other NPs I work with, and for the first time since graduating I felt like an experienced provider learning a new skill rather than a student. Similarly, I read this amazing piece on being a feminist health care provider from my professional hero, Feminist Midwife and changed the way I word things during a pelvic exam. I used to say, “If you can, I’ll have you let your knees fall out to the sides” before starting an exam. I have now changed that to, “When you’re ready, let your knees fall out to the sides” and will tell women that I will use her actions as a guide to her readiness for a pelvic exam.

6) Ask what questions a patient has right away. Don’t ask IF they have any questions. Everyone has questions, but ask what questions they have at the beginning of the visit and use those questions to guide your time together. Normalize questions by telling patients that their questions are common ones.

7) Don’t assume that any level of health literacy is too low. When discussing starting the pill I tell all my patients that they take the pill across the row, not down the column, and that they must be taken every day, not only with intercourse. For many people these concepts are second nature. For many patients in the population I work with they are not, so learn to anticipate the learning needs of your patients to make them more comfortable to ask the questions they have.

8) Apologize. Apologize when you realize that you have assumed someone’s gender identity, the genders of their partners, or that they are monogamous. I do my best to look over everyone’s social histories and make sure I am using the correct language, but sometimes I am overwhelmed and forget, or glance over it too quickly and assume. I did this a few weeks ago and assumed a male patient of mine had female partners. When he corrected me, I apologized for the assumption, and of course, he assured me it was not a big deal. As someone who most likely spends most of his life telling people it isn’t a big deal that they have assumed, and are incorrect, about one of the most core tenants of who he is, I made sure to apologize not only for the assumption, but also that I was sorry that I had created yet another instance of this constant cultural affront.

9) Listen to your patients. All my clinical trainers really want us to chart in the room. I do not chart in the room. I review the chart before hand and write down key things that I don’t want to forget to ask about on the fee ticket folder. I have maybe 10 minutes to connect with a patient, discuss the reason that they are here, and to come up with a plan, and I absolutely refuse for their to be any distractions to that precious sliver of time. I feel the creep of more and more reliance on electronic medical record systems and “meaningful use” quotas that I do not think actually improve patient care. I would rather spend my time face-to-face discussing a patient’s issue or diagnosis rather than use any time to find an article on it, print it, and then give that to them read over.

9a) Reiterate what you hear your patients saying to you, especially about their symptoms. I find it useful to use terms like, “So what I’m hearing is that….” Imagine if your health care provider not only understood what you were trying to get across but actively related it back to you. You’d feel important and listened to for sure.

10) Last but not least, take care of yourself. This past year has been a struggle to not only figure out who am inside the exam room, but also outside of it. Initially, overcoming the emotional exhaustion of being a midwife day in and day out was the most difficult. Then, it was reclaiming the self I know I can be in addition to the midwife in the office. Similarly, surround yourself with people that understand the work you do, will support you and love you, will keep you fresh and honest, and can also make you laugh about it all at the end of the day.

It’s been a helluva year, and (more details to come) 2015 will be another year of learning and growth and excitement. In the meantime, I raise my, now empty, cup of coffee to you all for reading along this past year and witnessing my transition from new grad to midwife.

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One Response to Year One

  1. JMT says:

    What a wonderful post. Your patients are fortunate to have such a thoughtful, reflective provider. Keep on fighting the good fight!

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