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.