Rambling

We are experiencing what seems to be an extreme shortage of clinical space and preceptors in our program, and probably programs around the country. Students spend a massive amount of time complaining about the lack of clinical sites, especially after dishing out six figures worth of tuition, fees, and living expenses for their midwifery education. I have been somewhat silent about all of this in my program because I feel like I have about as much clinical time as I can handle. It is true that I wish(ed) for my diverse clinical experiences, but at this point, just having a clinical site is about all I expect. I was talking to a professor about the challenges of recruiting clinical faculty to a program. Most of it made pretty good sense... 1) The pay isn't the greatest- you can make much more in private practice, which makes it hard to compete. 2) Academic faculty who have spent the last several years earning a PhD don't want to spend all their time in the clinical setting (duh, they got the degree to conduct research)

But the one that has me thinking is 3) We younger generation of midwives simply refuse to give our lives over to midwifery anymore, and she cited this as a major issue. I think this is interesting. She said her generation of midwives basically lived midwifery, it was very much a part of their identity. She spoke of how husbands would bring babies to midwives on site to be breastfed, and how it was possible because midwifery was the kind of profession that was woman/family friendly.

Times have changed.

My classmates and I often talk about balance as a pivotal part of life. Not one peer that I know of intends to give their life over to midwifery. Basically this means to be on call 24/7... to provide real continuity of care... to embody what I think many people think of when they think of midwives. In a recent conference day we had about malpractice, work environments, credentialing, privileging, etc we, as a group, made a list of the things we wanted/expected as working nurse-midwives. Most of us want dedicated call and clinical times... meaning you're not on call at the same time you're working in the clinic (many midwives do not have this- if someone goes into labor while they're working in the clinic, the must leave the clinic to catch the baby, and then come back to finish up... the patients are either re-scheduled or covered by another provider) We want something like 2 days of clinic and 2 days of call... and would be nice to not have clinic the day you come off call (ie- be on call from 7pm-7am on Thursday, going straight to clinic at 8am Friday) We want malpractice insurance to be covered by our employers (in most cases it is) We want good salaries... specifically, salaries that enable us to repay these massive loans. We want good benefits. The list went on and on. I kept looking at thinking, yeah this is a good dream list, but of course you have to give a little bit of something up, your first job isn't going to be perfect. Nonetheless, it's good to see it written on paper. The discussion moved to how practices are set up to ensure that midwives can have lives outside of work. Basically, in order for you to be on call only twice per week you need 3 other people in the practice who also take 2 days a week, or similar. This means that you won't ever really have real continuity of care because the patients you may see on a regular basis still only have about a 1 in 4 chance of actually having you present at their birth. Now, following the "it isn't about you, it's about them" logic, this might be ok... the woman meets each provider once, but sticks with you for prenatal care, but she understands that you may not be the one attending her delivery. This is how it's been done many, many places for quite a while and it's working out fine I guess. But what about the women you'd like to be present for, or who really, really are choosing midwives for continued care including the birth? Well, we call them "special" patients... meaning you either gave them your home number, or you made a note on the chart that you are to be called if they present to the labor floor. (At my institution, students call these patients their "continuity" patient - meaning it's one of the few, few patients they will get to see regularly in the clinic, and then be called when the woman goes into labor, no matter which student is actually on call that day. As far as I know, we're only allowed one... I haven't had one yet. AND if she goes in at a time when no midwifery faculty are on the clock- which is rather often, you still lose the opportunity) So when speaking to a newer midwife (graduated 2006) she was telling me that she used to "special" a lot of patients at first, when she was new, but now she hardly ever does. Why? because she doesn't want to be on call all the time. Which was precisely my professor's point.

I'm rambling, but it's just what's been on my mind as I contemplate what kind of midwife I want to be. I meeting with a new midwife tonight for coffee to discuss some of this stuff, maybe I'll walk away with even more perspective.