Students are so cool, and innovative, and on top of the most important issues – y’all probably already know that, but I want to point it out because it bears repeating! I was recently fortunate enough to be invited by a group of midwifery and nurse practitioner students to speak on a panel of fellow care providers regarding how to provide woman-centered care. My fellow panelists included a midwife who works at the (recently-opened) only freestanding birth center in Chicago, which accepts public aid, and a Nurse Practitioner at the feminist women’s health collective in town, which serves women and trans* people, regardless of ability to pay. What a crew, and an honor, to speak alongside the two of them! We chatted for well over our time limit about reproductive justice, contesting the binary of “women-centered” care as opposed to individualized/humanistic care, ideas of empowerment, and managing a busy schedule.
It is the last item on that list which providers, especially new providers, find the most challenging. Recently, a primary care doctor wrote about this specific struggle, that despite having 20 minute appointments that would appear well spaced and manageable, the day unavoidably goes awry. How does one start into practice with intentions of radical listening, fully informed consent, seeking empowerment models specific to each person’s needs, naming and breaking down issues of patriarchy / racism / misogyny, negating the power differential in healthcare settings, etc., and not lose those passions due to time constraints? It’s complicated, to say the least. I recently wrote about how to be a feminist care provider, but when it comes to fitting that into a tight time schedule, obviously the work becomes a bit more complicated. Truly the work is ours, as care providers, to manage and be kind about and patient toward its eccentricities and difficulties, but when it comes down to the nitty gritty of a patient who is angry because they have waited an hour, the day can wear thin.
I work at a Federally Qualified Health Center (FQHC): a busy community health center, with 15 minute appointments, even for new patients, many of which end up double booked on purpose or due to spontaneous walk-ins. Some days, this works perfectly: a healthy mix of repeat patients without complaints, multiparous prenatal visits with minimal questions, Depo shots and check-ins, etc. Some days, it works horribly: complications abound, ambulance calls, emotional emergencies, codes in the lab, and last minute complaints at the end of an already extended appointment. I love, love what I do, and the people I am honored to serve. I do not love the time constraints in which I do it. As a new provider, only 2.5 years into practice, I continue to seek ways to implement humanistic ideals into my care provision, even on the tightest constraints. Perhaps, though, our own intentions as providers can be squeezed in even when times are tough.
Here are some of the ideas I brought up on the panel, and others I try to implement every day:
- Control the schedule when you can: I have successfully negotiated 30 minute initial prenatal visits and IUD insertions, and point out when the scheduling was done incorectly and those visits were only scheduled for 15 minutes.
(That took some work, despite it seeming to be obvious that those visits take longer.) Even when it’s a day that is double booked or has many walk-ins, this scheduling structure creates a buffer for the longer visits when needed.
- Prepare in advance: I do what I can to get to clinic early and prep my schedule. I never like to walk into the room not knowing what is going on (for repeat patients), because I avoid looking at the computer at all costs during visits. I already have my plan in place before I walk into the room (ex: second trimester labs, primary care workup, HPV vaccination, ultrasound review, etc.), so that my tasks can wait to be discussed until the end (having already thought them through), and hers can be addressed at the beginning, face to face, without a computer screen between us.
- Streamline: Since I do not look at the computer while in the room (whenever possible), I took plenty of time to become familiar with my electronic record system and have almost every note standardized – Depo return visits, OCP counseling and prescription, return prenatals, postpartum, annual exams, primary care, IUD insertion and removal, UTI, chlamydia diagnosis, unplanned pregnancy, etc. All of these notes exist with only the individualized information missing. Ideally it takes moments to fill in these notes, even if there is an unexpected complaint. Streamlining takes all of the unnecessary mystery out of charting, and makes my SOAP note life dreamy.
- Know who is new: I am great at remembering faces, but not names. I have made the mistake far too many times of walking into the room and re-introducing myself to someone I met the week prior: not cool in the land of showing people I care and want them to feel confident in me and my brilliance. Thus, every morning, as I prep my schedule, I put a symbol next to the names of people who are new to me. That way I avoid looking like a jerk, when really I’m just running late and my brain is full.
- Remember holistic placement of your care: In each of my prepared notes, I have a “Social” portion that must be filled in or the note cannot be closed. This pertains more to individualized care than a making life manageable in a busy setting, but it does remind me of the broader positioning of my moments with someone in the greater scheme of their life, and my desire to check in on that. Examples: in school for dentistry and looking into scholarships, getting married in July – no babies until then!, negotiating with mother about driver’s license and extending curfew hours… What wonderful things to be able to check-in with people on, remind them that I do care, and that their lives matter in the healthcare that I provide. This part of my care is so, so important to me, and when I can create even a moment for it, I will. And, I think when someone has waited a long time for their visit, taking a few minutes to check in on them as people will make all the difference in apologizing for their care being late.
- Take the time when it’s warranted: 15 minutes is bogus. 30 minutes bogus. Really I would love most of the morning to sit down, get to know someone, figure out everything related to their needs and life desires, and structure a full hoslitic, social, and healthcare experience around that. I do not see the visit time-limit structure changing anytime soon, even with insurance reimbursement changing from quantity to quality. So, if I walk in and someone has an unplanned pregnancy and needs to talk about the stepwise process from today to the end of a termination, I will go over it as many times as they need to wrap their minds around it. If I walk in and someone says they feel unsafe at home and are ready to make a plan, I am going to take as much time as is needed to make them feel safe in the space around me and find a safe passage home and out of that home. If I walk in and someone has miscarried for the first time and is incredibly confused and overwhelmed, I am going to take the time to hold them and cry and wait until they are ready for me to let them go. Time flies, but when I need to recognize the importance of slowing it down, I will, and then skip to the “be honest” bullet point for the rest of the day.
- Be honest: “I am so sorry I’m running late: a patient had an emergency and needed extra time, and I will spend extra time with you today or in the future when you need it, too.” “I am so sorry the admission process took more time than you expected, but I am glad I was able to see you today.” “I am sorry to be running late, I know that waiting for a long period of time can be frustrating, but I am excited to see you and hear about what is going on with you and how we can work through that together.” “I am so sorry I am running late, and that you aren’t feeling well – start from the beginning and tell me how I can help.”
- Take care of yourself: Eat breakfast. Wear clothes that are comfortable and make you feel confident. Pee. Eat lunch. Laugh with your colleagues. Drink water. Pee again. Eat a piece of chocolate or your favorite snack, and close your eyes and savor it. Text a family member that you love them. Text a friend that you miss them. Turn your face to the sun around 2pm, even if for a few seconds, and breathe in and out a few times. It’s the same mantra that you have to take care of yourself to take care of others: being tired and making mistakes, being annoyed and distracted, being in a bad mood and putting off your patients – they all only take more time.
What about inpatient care? I have close friends who are bedside nurses, emergency department residents, laborists, and anesthesiologists. This “busy-ness” of this work, and the humanist aspect of it, is not secluded to outpatient. Here are a few ideas regarding the humanistic side of inpatient care (and perhaps others who work inpatient can speak to the managing the late-ness and busy-ness!):
- Make your first greeting not about the “stuff”: Every morning on the labor floor, I walk in and introduce myself and don’t “do” anything. I do not assess their cervix, I do not feel their belly, I do not tell them the plan. I walk in and say hi and introduce myself, meet their family, ask about their day, ask if I can bring them anything to eat or drink, and let them know that I will be back to get started. That way they have had a minute to have seen me and consider me as someone they know before I invade their space and take over their care (even though they don’t know yet that I will be giving them the power over their care and we will manage it collaboratively as possible). Then, I can cluster all of my care and not be distracted/delayed and forget tasks as I try to overlap the social and the healthcare. Also, I find this incredibly helpful if the next time I run into their room it’s for an emergency or a problem – that way they have seen me before.
- Be honest, breakdown power differentials, and be real: “Today is such a popular day for babies to be born! I’ll be running in between rooms, so here is your call button if you need to see me sooner than I get back to you.” “I am watching your monitor throughout the day, but I know that doesn’t tell me how you’re doing, so call me if you need me!” “You’re going to meet a lot of people today, but please know that I am your main person to reach out to if there are any difficulties or you have any questions.” “I know that some of this stuff can be scary, but please know that I will explain everything beforehand or as we do it in the case of an emergency, and reach out to me if you need me.”
- If you have someone who is your back-up, introduce them: If you will be stuck in a birth, or a surgery, or will be called away, and know who your back-up is, introduce them. Likelihood is, they’ll probably also be someone who comes in to help when sh*t hits the fan, and how nice to have more than one familiar face. This also allows for all of us as providers to focus on the care in emergency situations, rather than ensuring appropriate introductions have been made.
What suggestions do you have, for humanistic care in busy settings, either inpatient or outpatient? Again, please check out “12 Ways to Be a Feminist Healthcare Provider,” and leave feedback!