In every circle I meander, whether within the community or among consumers of midwifery care to professional groups and administration networks, discussion regarding the high rate of turn over among midwifery practices is consistent. My response is typically, “this is a really tough job.” There really is no better answer without writing a book… series… about the challenges we face and endure to the point of complete burnout and I can’t imagine anyone outside of the profession can even remotely wrap their head around the great challenges we face on a very regular basis.
The truth is that while midwifery is unique in itself among the healthcare population, medicine in itself is changing quickly and more challenges are presenting themselves almost daily. Midwives care not only for women, but for their spouses and their children. We are part of the childbearing experience which includes the entire family, and then as primary care providers for women, the needs of the entire family must be considered. Beyond the very deep and sincere relationships we build with each woman and her family, we sign into her concerns about financial stressors, access to care, medications and adequate nutrition, sleep deprivation, emotional health, sexual dysfunction, spirituality, loneliness, long-term health issues, parenting and marital concerns. Midwives must also continue to advocate at local, state, and national levels for those who are either too vulnerable, too young, too intimidated, too busy, or who haven’t found their voice. We are business owners, employers, accountants, web site developers, quality assurance officers, statisticians, billers, housekeepers and needless to say, the conglomeration of tasks goes on and on.
Not only does medical or midwifery education not prepare you for any component of independent practice or managing a business, but it doesn’t teach you about self care. What could be more crucial and critical in today’s medical environment! We recognize as clinicians that we can’t provide the best care to every patient within the conventional model and nearly half of all physicians share that they plan to get out of the profession in the next three years, and would not recommend the profession to their career because it simply isn’t satisfying (Ostbye et al, 2005 & CMA, 2001). We also know that the conventional model has worse outcome, and that 85% of patients leave the office without fully understanding what their doctor told them (Marvel et al, 1999).
However, we continue to strive towards this idea that we can fix the issues and make a difference with midwives facing some of the greatest battles since as a profession, we are still a bit on the outskirts of acceptance by our peers and by consumers. I can’t tell you how many times I’ve had a new parent tell me that their loved ones would like for them to get an opinion from “a real doctor.” Because we work to address the needs of our clients in a nearly impossible model with sometimes insurmountable challenges, we neglect ourselves. There just isn’t enough time to care for ourselves, our clients, our own families and support the profession itself. There is a sort of conflict between trying to heal others while doing so within a busy profession that demands attention to administrative tasks such as insurance claims, taxes, human resource regulations, and financial pressures that are quite literally defining the practice of medicine today.
Midwifery is Relationship Driven
There is a constant back-and-forth between the midwife and the client, which is so why so many of us are drawn to the profession. There is a give-and-take, an interactive fluctuating relationship. The relationship, in fact, is the core. All interactions are based upon a fundamental commitment to mutual respect, self-awareness, humility, openness and caring (Fetter Institute, 2004). Our relationships are complex and multifaceted and maybe no more complex are these relationships than during the childbearing year. Roles change, finances are particularly stretched, emotions are changing, and many are quite sleep deprived. Midwives want to address the “whole patient” which includes their families, their functioning body, their mind and spirit, and their relationships. All of this is consisted in individual treatment plans but what we often fail to consider is our own well being, satisfaction, and health habits. Many times we simply fail to take care of ourselves and we can not extend good midwifery care unless we commit to this seemingly simple principle!
The Personality of the Clinician
Interestingly, the evidence is mounting that the healthcare practitioner seems to have a specific personality. This may develop through our training, practice and medical or midwifery culture, or it may be intrinsic and what draws us to the profession in the first place. However, it seems quite clear that perfectionism and competitiveness, the need to succeed, is drawn out and because we always feel rushed for time, we deny our own needs. Healthcare providers are often opinionated, require delayed gratification (which is especially helpful for midwives), and we reward “workaholic” tendencies. We don’t set appropriate limits and reward ourselves for going above and beyond (any reasonable human expectation). We find personal weakness and vulnerability unacceptable, and are not trusting of others to do the job right. Our defenses make it hard to ask for help when needed, and we live within a culture of silence, keeping our problems, concerns and difficulties quiet. Our self-worth is wrapped up in our performance and we lose ourselves in the identify of becoming a midwife.
Inherent Stressors of the Medical & Midwifery Culture
There is no question that many of us are sleep deprived, yet while our clients articulate their acknowledgement of this, they clearly can’t grasp the concept. Their expectations often demonstrate a complete lack of awareness of our demands and unfortunately, because our sleep deprivation already makes us emotionally vulnerable, when client demands increase due most often to lack of patience or when we feel like we’ve failed you, we can become a bit fragile. Staying awake for 24 hours or more, sometimes many more, affects cognitive psychomotor performance as much as a blood alcohol level of 0.1% (above legal drinking limits).
Midwives who are stressed have more personal medical complaints, higher job turnover, earlier retirement and file more disability claims and ironically, many of us do not have a personal provider. Physicians often lack personal healthcare (34%) and they have a plethora of providers to choose from, while midwives aren’t typically as trusting and prefer integrative providers which aren’t nearly as accessible.
Burnout rates among practicing physicians ranges from 25% to 60% and while I am not sure if midwifery rates are available, my assumption is that they are double, if not triple this number, although for very different reasons. Physicians report their primary concern being suboptimal patient care and that their burnout, depression, and stress started in residency or even medical school, before they even began to practice! Midwives are all agreeing here, with a hearty amen!
Sadly, physicians are 2.3 times more likely to commit suicide compared to the general population. I have blogged previously about nurses doing the same for a variety of reasons, but most frequently following a scenario in which they felt their failed their patient. Female physicians have suicide rates that are four times higher than females in the general population and is found as the most common cause of death in young physicians, accounting for 26% of all deaths.
Alcohol and drug abuse is another significant issue and one that is so common, it is the norm within the medical culture. We all know a healthcare clinician who struggles with addiction and this is the primary focus of the medical and nursing board. Ten to 14% of all physicians are found to be addicted to drugs or alcohol while practicing and of course, this only counts those whose addiction who became significant enough to alarm the medical board, because many are practicing with additions that either go unrecognized or are socially accepted among a profession who identifies with the great challenges of our daily work life.
Fentanyl is the most common drug of abuse and in one study, 18% of healthcare providers died or almost died before substance abuse was even suspected. Admittedly, I have worked for a few managers who would pass out at their desks from drug abuse, or even in the parking lot before making it up to the unit. I have worked alongside nurses and physicians who were stealing pain medications from clients and I’ve been on shift when a physician started her own IV, administered her own medications, and demised from aspirating her own vomit. I have also known and worked with home birth midwives who were addicted to drugs, most often pain medications, because they neglected themselves or had to utilize medications to meet the demands of their clientele base.
Divorce as well, is commonplace is our profession, estimated to be 10 to 20% higher than among the general population. When the clinician is a female, the divorce rates are even higher which of course, is true of midwives. We are challenged to be present 100% of the time to our clients and also care for our children and spouses. Long work hours, stress, trauma, sleep deprivation, and even grief all contribute to increased divorce rates in clinician relationships.
These past two years, our practice has worked very diligently in creating healthy boundaries. This has been a rude awakening to a few clients, and proven impossible for some of our previous staff. However, it is a non-negotiable that our current team is strictly committed and is regularly called accountable. We limit our hours, our commitments, under promise (over deliver), and absolutely, without exception, must live what we preach. No more working from home!
Clearly, not matter what the job, it seems intuitive that the happier a worker is, the higher their quality of work. This not only holds true in medicine and midwifery care, but it also impacts the client’s experience, quality of care, thoroughness of care, and how well the client adheres the the treatment plan. Midwives should model self-care. Admittedly, I adore when I am talking about a treatment plan with a client and my clinic coordinator, who really hasn’t clinical training, voices her own personal experience having implemented some of these treatment plans into her own life. We speak from experience, and as many of you have witnessed, implementing these strategies and finally learning to draw healthy boundaries myself has meant that I weight less today, at 39 weeks of pregnancy, than I did just last summer. I am not restricting calories, depriving myself, or quite honestly even exercising regularly because I am guarding my adrenals currently, but because I am managing my stress, prioritizing sleep, and focusing on healthy living, my body is shedding weight weekly while growing a child.
Studies have demonstrated that when physicians are “professionally satisfied” in their work, they provide better quality of care and produce more patient satisfaction (Haas, 2001). Physician’s satisfaction is also directly correlated to their patient’s overall compliance with their treatment plans. The power of that provider-patient relationship is integral to clinician satisfaction. Again, we have taken this to heart and have set boundaries to optimize our success in these ways. Our programs allow for far greater time with each client, allow us to actually educate our clients which improves commitment to the plan, and our relationship is deepened. This has changed our clientele base however, as some prefer the al la carte option of midwifery care, taking only what they want and not investing in the relationship itself. We have chosen to not accept all those who would be agreeable to hiring us, but rather only those who we feel we can connect. We have complete confidence this is best for all of us, although this is a concept our consumer driven culture is certainly not accustomed.
Primary care physicians who had good personal health habits provided better preventative medicine counseling and screenings for their patients (Frank, 2000).
Being Called Accountable
Two years ago, I was called out by a doctor who said I was over-weight. Without apology, he continued to argue that neglecting my own care was a matter of integrity and my clients will, and should, judge me on that fact. My response at the time was, “this is what all midwives look like! We all have adrenal fatigue eventually.” While true, it is an excuse and evidence of not creating healthy boundaries.
I took his comment to heart and was grateful that he respected me enough to be so blatantly honest. It was an important message that I needed to hear, particularly if I was going to continue in this profession successfully. I have continued to extend this accountability to my own staff. I have been known to pull staff into performance reviews because they were not prioritizing their own healthcare and admittedly, have reduced responsibilities and scheduled work time until the employee could demonstrate they had reestablished a commitment to self-care.
Bullying has been a frequent topic on this blog, and it is part of the reality service workers face, especially within healthcare. Add to that the emotional vulnerability that stems from the demands of the job otherwise, midwives and our team member can be especially victimized. However, I think what keeps us going, what maintains our satisfaction in the midwifery profession, is the realization that we are providing exceptional care and our clients are greatly benefited by the work we do. As we align our own personal boundaries with what we extend to our clients, compliance with treatment plans is improved and stories of life transformations become regular testimonies within our typical clinic day.
Asking for Help
Our profession is just not one to do so! Not only do we feel it is our role to serve, but it is not socially acceptable among our associates. We must always demonstrate success and any request for help is viewed as weakness, failure, or inadequacy. Practitioners withdraw, become anti-social, and worry obsessively. There are now more formal and informal groups supporting this connection among clinicians which is vital, but signs to be aware of include increased physical problems or illnesses, increased problems with relationships, increased negative thoughts or feelings about people or things you use to enjoy, increased unhealthy behaviors, and the inability to continue to push oneself.
If we are to see ourselves surpassed, we must draw healthy boundaries that will allow us to endure through the long haul and to create a profession that is attractive to those who will come behind us. We must find our strength and encourage each other. We must remember the essential nature of this work and renew our sense of calling.
What does Wellness Mean to You?
What is most relevant for wellness to you? Where are your priorities for your relationships? Are you involved in your community? How much tie are you spending with your family? Do you have friends? Consider your spiritual life. Are you active in the church? Are you attending services? Do you pray or read the Bible? Do you have a hobby? Do you vacation? Do you exercise or meditate? Are you nutritionally mindful? Do you avoid drugs and alcohol? Do you get counseling? Do you recognize toxic relationships and free yourself from them? Do you have limits in your work life? What are your professional boundaries? What are your work philosophies, or what I like to call, your non-negotiables. Write them down and share them with others.
Do you journal? What surprised you today? What moved you? What inspired you? What are your goals? Break the culture of silence. Are you spiritually well? What would nurture you? What would allow you to personally and professionally grow? What would help you sustain the day-to-day challenges? How can you connect better to the meaning of your work? How do you define health and healing? What is your personal philosophy about health? Does you life reflect hose values? What values would you want your patients and colleagues to recognize in your behaviors? What can you do to optimize living the life your preach?
Once a provider is committed to honoring personal wellness as a way to further his/her professional work, the possibility emerges for their entire clientele to find personal healing.
Integrative and Functional Midwifery
Our new practice model is intentional. We worked to create a practice model that not only offered the best to our clients, but also supported a healthy environment for our staff, because midwifery is hard. I think it could be argued that it is among the hardest of all professions. It is also among the most rewarding.
Our new balance is evident in our own health, our commitment, and our client’s success.