Tuesday, May 09, 2006

Patient Satisfaction

One thing that is not debatable is that patients of midwives are far more satisfied with their experience than patients of obstetricians. I suspect that this is due in part to the fact that midwives spend far more time with patients than obstetricians. This is especially true in labor when the obstetrician probably spends less than 5 minutes with a patient per hour whereas a midwife might be present and providing support the entire time.

There may be more to it, though, than simply support. Patients tend to pick their midwives specifically because of compatible philosophy. Moreover, patients who choose midwives tend to be white, well educated and from a Western culture, in other words, very similar to the midwives themselves.

I always found that one of the hardest parts of practicing medicine was meeting expectations when I didn't know what the expectations were going to be. I could spend time with one patient in labor who would make me promise not to offer an epidural, then go across the hall and try to explain to another patient why she couldn't have an epidural at 1 cm because it would make her labor stall.

Do you think that the very high satisfaction with midwives is due to the support they offer, the compatibility with their patients, or a combination? Do you think patient satisfaction would be as high if the midwives cared for all patients, as opposed to those who specifically chose them?

7 Old Comments:

The big difference I see with my clients is I do not treat them as patients. They have not entered medical care for the treatment of pregnancy as a disease process when seeking midwifery care for normal low-risk pregnancy. Sure, some women do need medical treatment and they ARE patients of obstetricians or even certified nurse-midwives with a hospital based, higher risk practice.

I would hope that clients would choose their physicians based on similar philosophy. How often do physicians hold consultations for prospective clients where their initial questions are answered before ever filling out contract for care? Women expect this of midwives, even hospital based, why not of physicians?

Recently a friend of mine had a hospital birth and I acted as her doula. The doctor she loved and had a great rapport with was off call, but IMHO a great doctor caught the baby in her stead. She didn't hear from the practice again (she knew the docs on a semi-personal level since her husband is also an MD) until she tried to make her 6 week pp visit and found out the doctors she had left. I was the one who tracked them down through professional channels for her to make the appointment. The doc she liked barely remembered she had a baby and referred her back to the practice she left for f/u when it was just as easy to see her for a visit. The whole thing has left her feeling abandoned. So now two practices, one established and one new, have a negative rating with one client with a far reach in her community.

It really doesn't take a lot to impress anyone, much less a pregnant woman. Listen, be present. It's not rocket science. I get women all the time who are not the "home birth type" but resort to it out of frustration with past or current issues with their care providers. My question is why, if physicians are aware of this, are they not making a larger effort to increase customer satisfaction? Is that the population of women giving birth in the hospital is so large and in a sense, a throw-away population, it doesn't matter? A pregnant woman is a like a bus... another one will be along shortly?

By Anonymous MetroMidwife, at 12:39 PM  

"My question is why, if physicians are aware of this, are they not making a larger effort to increase customer satisfaction? Is that the population of women giving birth in the hospital is so large and in a sense, a throw-away population, it doesn't matter? A pregnant woman is a like a bus... another one will be along shortly?"

There is certainly plenty of room for improvement in doctors' bedside manner, and they should be more caring and less preemptory in their manner. However, the biggest problem is that different patients want different things.

Let me give you one unusual example. Whenever I delivered the baby, I offered the father the opportunity to cut the cord. Most fathers were really excited to do it. A few refused because they were squeemish. However, not once, but twice in my career, the father turned to me and said: "Why would I do it? What the f*** did we hire you for anyway?"

That's pretty extreme, I know, but it illustrates the point that there are many ways to let down a patient.

Patient expectations about pregnancy and labor, and what they expect from their obstetrician vary dramatically from culture to culture. There is a gaping chasm of difference between caring for a 14 year old who has her thumb in her mouth during labor (yes, this has happened to me) to caring for a woman who is highly educated. Many patients have special needs, including women who have been the victims of sexual violence and women who have been the victims of female genital mutilation.

That's why I wonder what the satisfaction rate for midwives would be if they cared for the broad spectrum of women, instead of women who are very much like themselves.

By Blogger Amy Tuteur, MD, at 2:44 PM  

That's why I wonder what the satisfaction rate for midwives would be if they cared for the broad spectrum of women, instead of women who are very much like themselves.

More often than not, the thing I have in common with my clients is the desire to give birth at home. I adapt to fit the need of the client and work hard not to push any agendas. And I don't pick the client like me, they pick me based on whatever criteria they've decided and because they're paying out of pocket it is even more personal than picking your OB out of a catalog because the clinic is down the road.

Back to consultations: During the first meeting with the potential client, she and her husband lay down their expectations, including whether or not the father will cut the cord. Perhaps spending more than 7 minutes an hour with your clients in labor will avoid such eruptions from unhappy fathers? btw if that is the most extreme example you can give of patient dissatisfaction, I imagine you were providing satisfying care while practicing.

By Anonymous MetroMidwife, at 3:50 PM  

Amy, a LOT of CNMs are working with inner city indigent women and in the Indian Health Service.

By Anonymous maribeth, CNM, at 3:54 PM  

we have had more than one dad say something similar of course we are not approaching dad for the first time at the birth saying do you want to cut the cord or help catch the baby-- I have heard those exact words-"Why would I do it? What the f*** did we hire you for anyway?" -and I have also had a few of those dads by the time the baby is born to change his mind and want to be far more involved.
The care is not in just one detail- it is an approach- this is your baby your birth I am here to help- assist in what ever way I can or to stay out of the way if that is what would best serve. one of my all time favorite docs was an ex-missionary - she was a very experienced and humble woman who had seen and done alot , she seemed to have no end to her calm nor limit to her attention-she sat with many moms in labor not just walking in and then out again.
yes I have done births for young teen moms who were molested, or who were gang members- many many many sex workers or ex-sex workers- clean drug addicts - women who are married , single women. families from different cultures, deaf families, blind, plural marriages, lesbians, women who adopted their babies out . women in abusive relationships I do not think that I am unique to this as I have worked with many other midwives-through the years -- One of the first births I was at the father sat at the end of the couch bed about 2 feet from the TV watching football and he did not take his eyes of the set the whole time-
one of the key things about midwifery is approach- birth is normal and usually a state of good health, most babies come out safely- I know you can say a retort and not all babies or mothers are safe I agree- if all were safe no assistance would be needed at all.

By Anonymous Anonymous, at 5:08 AM  

I volunteer with soon to be moms (mostly teens and moms with disbilities) and often I am asked to accompany them...

What I have seen is this:

OB: Long wait in office, talk down to the "patient", won't explain things, stuck-up attitude, use scare tacticts way too often, don't ask questions beyond the "list" that they seem to have etc...
Basically they don't have time, look like they don't want to be there, don't listen and are always in a hurry and there is NO emotional connection made.

What I know of my expereinces:

Midwifes: No wait time, Take time to ask about expectations, ask about non-pregnancy issues that may effect the pregnancy (support, marriage etc) less scare tactics, make you feel like they want to be there and you are no a burden to them...

By Anonymous melissa, at 7:32 AM  

I think it has to do with motivations. When a caretaker is concerned with the individual and trying to help them have the experience they want, it shows through in the kind of care they give. Midwives are generally committed to personal care and to preserving normal birth.

But when a caretaker is more concerned with protecting themselves from lawsuits, that too shows through. Women feel treated roughly and impersonally.

Let me use c-sections as an example. Midwives will try hard to avoid a c-section if possible, using position changes, relaxation, and movement to promote a vaginal birth.

Doctors, on the other hand, truly don't care whether a woman has a c-section or a vaginal birth - in fact, they usually prefer the section.

This is apparent in how they care for childbearing women.

By Anonymous Anonymous, at 10:58 AM