By Stephanie Tillman, CNM, MSN
Perhaps one of the most
tenuous aspects of working as a new graduate midwife is developing a
collaborative relationship with physicians. In the physician-midwife, as well
as physician-nurse practitioner or physician-physician assistant relationship,
there are many factors at play: power differentials, scopes of practice, health
and care provision belief systems, historical interactions of each provider
with others in the same field, and experiences in prior collaborative
relationships.
When I first started midwifery
practice, I worked at 2 different clinics, with 2 different collaborating physicians
who had 2 very different styles of practice. I never worked simultaneously with
either of them, so our communication was linked only through my referrals to
them, or the rare text message for quick questions.
I recently started at a
new clinic within the same organization, and now have one collaborative
provider. She and I work similar days, so we often overlap not only time in the
clinic, but also office space, rooms, medical assistants, and patients. The
difference in our relationship is
palpable: she hears my discussions with patients in the hallways, my
communication with the medical assistants for scheduling and testing, and my
counseling to women and their families. A strong relationship will be needed to
facilitate a group approach to our practice.
I also work once per
week at a hospital, where each day is different. Each shift, I have 2 collaborating
physicians from a group of over ten 10 possible, including my current clinic
collaborator. That’s a lot of collaborating relationships to develop. That’s a
lot of personalities. That’s a lot of belief systems. That’s a lot of
opportunity for hiccups – to put it mildly – in patient care if smooth
communication and a positive collaborative relationship have not been
established.
I haven’t even come
close yet to developing the perfect relationship with any of my collaborative
providers. I am only just beginning this, and still have a lot of work to do. I
plan to work carefully and patiently with my newest clinic collaborator to
build a strong relationship and develop trust – on both sides. Already, we have
had differing opinions on practice, and both disagreements and agreements over
more casual topics. We each have room to improve, but I believe we can keep
dialogue open and allow space for disagreements while maintaining respect for different
approaches. So, I have been thinking about the collaborative relationship, and
thinking hard because I want to get it right. As I make a list and check it
twice, I share my thoughts about how I might develop a strong foundation:
Find common ground. Get to know each other holistically, as you
would get to know anyone else with whom you develop a relationship. What
brought you to your current place in life? What do they love about their work?
What are their struggles? What is their life outside of work? Do they have
prior experiences with midwives? If not, start out with your individual
approach to your work: your mantra, your midwife or prior work experience, and
your goals for collaborative practice.
Talk about the basics. We all know there are grey spaces in approaches
to health care. Address them head on! Work toward creating a shared mental
model of approaches: Where are you going to cut off the 1 hour glucola, or will
you do the 2 hour? At what BMI might you do additional testing? What are the genetic
screening options available and which do you each prefer? Are they open to your
expanding your scope of practice and bringing those to the clinic or hospital,
such as with colposcopy, biopsy, ultrasound, or surgical first assist? Clarify
any grey areas in the collaborative agreement regarding which individuals would
qualify for midwife-only care, collaborative care, or transferred care.
Discuss what to do when
you disagree. There will be times when
you disagree with your collaborator. How will you approach the discussion?
Address concerns about any prior situation when the physician ignored your
input and assumed higher knowledge. Similarly, discuss times when the physician
respected your opinions and included you in the final decision-making process –
which is how it should be, but often isn’t, so I will definitely be including
the compliment-sandwich approach as I move forward! And, if no consensus can be
reached, review the organization or hospital’s process.
Emphasize the team
approach. I always discuss with
patients how I work on a team with other midwives and doctors. Does your
collaborator do the same? Bringing up the team is important for all providers,
since the individual or family may see multiple people throughout their care.
If I am meeting someone who has seen another provider previously, I will often
introduce myself, saying, “Hi, I’m Stephanie. I work with Dr. ___.” This usually
makes a big difference in the patient identifying team care. Naming this team
identification process opens the door for the collaborating physician to do the
same.
Share resources and
referrals. Have a favorite
chiropractor or acupuncturist? Love ACNM’s “Share with Women” or the RHAP’s Fact Sheet handouts? Does your collaborator know a great vulvar
dermatologist? Want to help discuss Spinning Babies methods in the third trimester to prevent the need for
a version? Discuss your resources and referrals, and un-silo the work
relationship. Create mutual handout packets or referral lists that you can
share.
I welcome others’
thoughts about what works and what doesn’t in navigating a new midwife-physician
collaborative relationship. I hope that this list is just the beginning in
developing a resource for new graduates and experienced midwives alike who seek
to form a positive collaborative relationship with all other providers.
What are your
experiences in creating collaborative relationships? Have you experienced
successes or roadblocks? What suggestions do you have, especially for new
graduates, in creating a positive collaborative relationship?
Stephanie Tillman is a
recently-graduated nurse-midwife now practicing full-scope midwifery in the
urban United States, at a Federally Qualified Health Center (FQHC) and as a
member of the National Health Service Corps (NHSC). With a background in global
health and experience in international clinical care, the impact of public
health and the broader profession of midwifery are present in all her thoughts
and works. Stephanie's blog, Feminist
Midwife, discusses issues related to women, health, and care. Find out
more at www.feministmidwife.com and follow her on Twitter at @feministmidwife.