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Join us as we dive deeper into the rising severe maternal morbidity and maternal mortality rates in the United States through a data-driven, quality improvement lens. Each episode will foster discussion with those committed to improving maternal health outcomes and saving lives.
Christie - 00:00:05:
Welcome to AIM for Safer Birth. I'm your host, Christie Allen, Senior Director of Quality Improvement and Programs at the American College of Obstetricians and Gynecologists, or ACOG. And on this podcast, we dive deeper into the severe maternal morbidity and maternal mortality rates in the United States through a data-driven quality improvement lens. In this episode, I am joined again by Dr. Veronica Gillispie-Bell, who we've talked to a couple times, an entire season for season one, and then once already this season. We wanna kind of wrap up the season that we had, this time around, and talk about some of the current issues. We've had threads through the entire season two, where we've talked about rural maternity care and collaborative care. And so we're gonna do a little talking about that today. So welcome, Dr. Gillispie-Bell.
Veronica - 00:00:51:
Thank you for having me back again.
Christie - 00:00:53:
It's always a pleasure to talk to you. And we're fortunate that we get to do that a fair amount in different settings. Anyone who is interested in Dr. Gillispie-Bell's bio, we have it on the AIM website, saferbirth.org. And you're welcome to read her very impressive bio. But if I start that, it's going to take a lot of our time today. So we're just going to talk. I mentioned as I was starting, you know, the threads that we've had, you know, in season two, and I'm just going to run through sort of the trajectory of our season. We had a mini series that hopefully you're aware of about rural maternity care. And we called it You Can't Get There From Here, which is sort of a New Englandism more than anywhere else. When you ask someone for directions and they're like, yeah, You Can't Get There From Here. I don't think you understand that unless you've lived in a rural environment. But where you're, those are the limitations. I was fortunate to talk to folks at sort of the government, the office, Federal Office of Rural Health Policy, and Dr. Dillon there talking about their objectives. We connected with Indian Health Services representative, Dr. Tina Patar Lau, who told us about the great emergency readiness work they're doing and some of the barriers they face uniquely. And then we've sort of moved on through other variety of subjects that we can get to. But I'd love to start off talking about rural health since that is such a topic right now. So I know you have some backgrounds in this and we've talked about it a little bit. Do you want to talk a little about your experience and your observations of late?
Veronica - 00:02:15:
I will say from a state perspective from Louisiana, we're seeing a shift in where our patients are having to be cared for because we're seeing more and more hospitals that are cutting back on obstetric services. And it's not unique to Louisiana. We're seeing it across the entire country. I think the last report that I saw, the most number of closures have been in Florida. So we're talking about in rural areas where there's already decreased access, we're seeing even more decrease in access because hospitals are closing and it's really forcing us to need to improve readiness in non-obstetric places where we had not, that's really a place where we really haven't focused as much. And so I know that the AIM has also been working on preparing bundles and toolkits for obstetric readiness in those non-obstetric areas. For us as a state, our Perinatal Quality Collaborative have an initiative called the Obstetric Readiness and Emergency Departments that's going to launch in 2025. We're planting the seeds now, but it's really around the response that we feel like we need to have towards these hospitals closing and patients really having to get their obstetric care in emergency departments, which is really unfortunate because those providers are very ill equipped to handle obstetric anything, especially emergencies.
Christie - 00:03:47:
So I want to highlight in saying that our emergency department colleagues are generalists in the best possible way. They see all kinds of things that we don't see in obstetrics. And, you know, there's certain topics that I feel like they're more prepared to deal with than we are at times. But traditionally, for those that aren't aware, obstetric care was very immediately moved to obstetric units. And there's a lot of anxiety, I think, for healthcare providers who don't work in obstetrics, that you suddenly have, you know, two patients was the old thing that we used to say. But I think some of it is a construct, right, around birth is healthy and people shouldn't be sick. And we know that that is always the goal, but it's not always the reality. Have actually huge respect for our emergency medicine colleagues who are suddenly the safety net on top of being a safety net for folks that have social and structural drivers of health that they're really struggling with. And a variety of other things, right? People don't go to the emergency department because things are going well. And so I feel like we're asking a lot. And so we need to help equip folks. And it sounds like that's kind of a similar bent AIM has and Louisiana does as well.
Veronica - 00:04:56:
Exactly. As you mentioned, the emergency department is supposed to be for that, emergencies, but it has become a place of primary care, not just in obstetrics, but outside of obstetrics as well. And so we really are asking our emergency department providers to stretch beyond their training and to stretch beyond their capacity. It's a bottleneck effect. And we saw that during COVID-19. And I think we're going to continue to see that as we see in obstetrics hospital closures. And so the patients that really need emergency care are not able to get it because there's routine care, which should be moved to different settings that are having to occur in the emergency department.
Christie - 00:05:42:
So I want to talk a little bit about closures for a minute. And I should preface that probably by saying neither you nor I are experts on all of the policy and procedure ramifications of that, right? It's a little bit anecdotal and speculative, but the evidence is there. We know that there's closures. We have seen the increase in maternity care deserts where folks don't have access to obstetric OBGYN care. And we've seen the impacts of that with obstetric emergencies presenting in places that are not either prepared or equipped to deal with them. What is your take on the current closure thing? To be really honest, I've been hearing about it for years, and I'm a little, maybe wasn't hearing it for the true emergency this is creating right now. So I feel like we're at a little bit of a tipping point. Why do you think that is?
Veronica - 00:06:29:
I think it's a confluence of things. As we were kind of talking before we started the podcast, we are still coming out, if we want to say coming out of the COVID-19 pandemic. And I think resources were really, really stretched during that time from a financial standpoint. And so we've not recovered from that. And we see that in the hospital in a number of ways. I think that's one part of it. I think also, well, it's not just my thought. This was a JAMA article. If we look at reimbursement rate for obstetric services, the reimbursement rates have remained very low, especially when we think about Medicaid reimbursement. And so in a state like mine, where 62% of our births are covered by Medicaid and the reimbursement rate is not even comparable to the Medicare rate, how are hospitals supposed to stay open? We know in general hospitals lose, quote unquote, lose on obstetric services from a financial standpoint. But now they're not even able to make that up in other ways. And some of it is because we're doing better quality of care for non-obstetric things. So patients are not in the hospital as long. So for example, I do a lot of, even though I talk a lot about obstetrics, in clinically, I provide a lot of care in terms of fibroids. And some of the treatments that we're doing now, even with a hysterectomy, when I started in practice, that patient would have been in the hospital at least a day for a laparoscopic hysterectomy. Those patients are going home the same day now. So that also, because we don't have those inpatient services, which is better for the patient, but then what does that mean in terms of reimbursement? We just really have not changed our pay system in the US so that we're paying for value instead of volume. And so because of that, especially in these hospitals that are more rural areas where they have lower delivery numbers, the reimbursement rates are lower. Having to pay really for 20, think about it, for obstetric services, you need a 24-hour coverage from nurses to physicians to all of that. And the reimbursement to provide those services is just really not there in the way that it needs to be for hospitals to stay open. And again, in addition to the financial recovery that we're all experiencing because of the pandemic.
Christie - 00:08:50:
Yeah, it's so hard to talk about money and this, right? Because we're passionate about the work and the people, but we exist in very real context and our healthcare system does as well. And we're working within that. I know that ACOG's team, my colleagues work very hard around reimbursement and talking to government factors, to insurance companies and all of those. But I think until we start valuing the care that's being given to the patients and essentially valuing the patient's quality of care, we're always going to be running up against this. Also, generally speaking, I know we talk about for-profit and healthcare and there's a lot of truth to the financial issues. I also wanna be clear that there are a lot of nonprofit hospitals that need to keep the lights on. Like realistically, as an administrator type human, you can be very passionate about wanting to provide optimal care and not able to continue to pay the people to do that. I think there are also some restrictions that we know on reproductive healthcare, state to state. And there are some clinicians we already have physician and midwifery shortages as well as other clinicians. And those folks are not any more free to practice in those states in a way that aligns with their patient's needs. And so very understandably, they have not continued to do so. And it's that confluence you're talking about. It's a little bit of a, we took what was already a really tenuous situation and we layered a global pandemic on it. Hospitals had to increase their pay for nursing staff, for clinicians. They weren't bursing in the same way. They had different volumes and they couldn't do elective surgery. And as someone who actually had a hysterectomy a few years ago and went home two hours later, I actually really recommend it. It was wonderful to be home. It was better for me. I don't, like, it's not that we're booting people out of the hospital before they're ready. It was better. I was walking. I was eating. I felt fine. It was great to be in my own bed with my own pillows and fighting off my own cat. But I think there is something there. Where we, you know, the reimbursement hasn't caught up and the policy hasn't caught up. So I want to acknowledge all of those realities because this isn't that like, you know, big business doesn't care and that's why the whole thing is happening. There are always underlying social and structural systems in place that we may not align with personally or professionally. But I'm going to say also there are so many factors. So I think all of that context is very important as we talk about closures, because then our focus needs to be on, but what about the people that are there? And we've talked a lot during this podcast about people wanting to stay in their own communities, and that's incredibly valid. I also want to be cared for, as I just mentioned, in my own space, in my own community, not to mention the logistics of moving people around hours and hours and emergencies. So that's really helpful context, I think, as we think about next steps. And part of what we moved to with the rural care was talking about systems and structures of care. We then we also talked to Amy Romano, who has primary maternity care and works with birth centers. On quality and safety as a midwife. And those are not affiliated with hospitals necessarily, but they're collaborating. They're doing simulations and drills with hospitals. And they're really talking about, I don't know that we're all there, but Amy was talking about how we could provide some primary maternity care in other locations. Is that something you're looking at in Louisiana or you've heard nationally?
Veronica - 00:12:13:
So the LAPQC has been very busy. I mentioned that in January 2025, we're going to be launching our obstetric readiness and emergency department initiatives, but we just launched a community birth initiative. And this initiative is really for our freestanding birth centers, which recently licensure rules around like hospital licensure or freestanding birth center licensure was passed in Louisiana. And so we're starting to work with those licensed birth centers on some of the things that we do in the hospitals around hemorrhage and things like that. But really what we're focusing on is transitions of care and trying to improve the relationship between community births and hospitals. I think Louisiana is not unique. We have some states definitely that are really leading the way like Washington in how to do this. But because we don't have great relationships between birth centers, community births in general and hospitals, it really has created this really budding of heads. And so we're using this initiative to try to improve those relationships. As well as there's legislation we have going on to also look at how we can make freestanding birth centers more accessible to our patients, to decrease some of the regulatory requirements for the freestanding birth centers to exist in Louisiana. And I really do think that that is going to be important as we think about the deserts and we think about how can we bring care to the patients instead of making the patients come to care. I've said this in many, many interviews and other podcasts. I really think that that's very, very important. To your point, patients want to stay in their community. They don't want to drive, you know, I always use this analogy. It's not going to resonate if you're not in Louisiana. If I am in New Orleans and I'm talking to a patient in Houma, Louisiana, if I tell them they have to go to New Orleans to get specialty care, I might as well have said they need to go to New York. Like, it's the same for them. They want to stay in their community. So we have to think about how we bring care to those communities. Truth be told, we're probably not going to be opening new hospitals. It's going to be a lot more than we can do, I think, in addressing some of those things that we talked about that's leading to hospital closures or at least hospitals not doing obstetric care. But what we can do is we can decrease some of the barriers for those individuals, midwives, birth centers that want to practice in those rural areas.
Christie - 00:14:54:
Yeah, I think that was some of the helpful conversations throughout this podcast for my learning as I talked to a maternal fetal medicine specialist who works with outlying facilities and sort of the relationships she's talking about. They have my cell number and they know to call me and I know how to help them. And they really talk about keeping the patient at the center. I think with community birth, it's a similar thing. AIM has recently launched the Community Birth Transfer Resource Kit. And Louisiana might have gotten a sneak peek at that even before it was published. But it's exactly what you're describing of building those strong relationships so that you're not having to do it in the trenches, so to speak. No patient deserves to have providers that are uncomfortable working together or speaking sort of different languages, if you will. Because they do have the same goals at the end of the day. We all want our patients to thrive and to be healthy and to get what they need. So I'm excited about that work. I'm excited about thinking outside the box with some of these strategies. And I think AIM is going to be here to support whatever those outside the box thoughts are. We also talked over the course of AIM. I spoke with Dr. Elliot Main about sort of the history of the work in AIM and where it's going. And I've been fortunate to start leaning into some work around sustainability. Sustainability is another thing that's being talked about a fair amount, which I think is age appropriate, if you will, for some of the work we're doing in maternal health. We are all wrapping things that we've already gotten started. And you and I have discussed this ad nauseum, right, that the bundles don't end. They keep going. You integrate practices. So sustainability in this work. Had we had that, I think could have potentially helped with where we are now with closures. So it's not just an act, right?
Veronica - 00:16:40:
A hundred percent. As we were talking, the Donabedian model always in my head, I was thinking structure drives process, drives outcome. Our structures were not in place and the outcome is that we're having hospital closures. And so you're right. It's thinking about the sustainability part. How do we create it so that the workflows, those processes, those things are integrated fully into what we do? And what happens if they're not when you put pressure on the system, then they fall apart. And that is what that's exactly what we're seeing. And we saw it, you know, with different clinical conditions during the pandemic as well. And it really made us rethink about, for example, our addressing hypertension. We had addressed hemorrhage and hypertension from just speaking from a clinical standpoint. Those those bundles in Louisiana. And we saw that even after throughout the pandemic and after the pandemic, our severe maternal morbidity related to hemorrhage continued to decrease, whereas hypertension fluctuated. And so that made us say, okay, wait, this means that our structures and processes for addressing hypertension are not in sustainability mode. We need to continue to work on those processes and structures and hemorrhage. Yeah, we can move that to sustainability, which, to your point, does not mean you stop working on it or that you take your eye off. That's not how quality improvement works, but making it more into a sustainability mode so that we can focus on some of those other processes, especially as you mentioned. There's so many things when we talk about maternal morbidity and maternal mortality that have to be addressed. And so it is a little bit of pushing the gas and pushing the clutch for those of us that drive manual transmittal cars. It's a little bit of pushing the gas, pushing the clutch and how to balance that out, because you do need to continue to work on new things. But you have to have other things that you have worked on in a in a state where they can be sustained.
Christie - 00:18:46:
Mm-hmm, mm-hmm. Yeah, and I think we sometimes don't put those pieces together that like, oh, we're short on this kind of clinician. Why? Go back. Like, did we not value that profession so students didn't go into it and now we have a shortage? Were people not told they were capable of doing it? You know, we don't have enough black physicians out in the world taking care of patients. Why? That didn't happen today. What we're seeing is the growth from the roots of what exists. And I think that is never clearer than in obstetric and maternal health care. We are dealing with the growth from old roots. And I... Flip that a little bit because my role is now to look at, as I see it as a professional and as a human, is to look at what I'm putting in the ground right now, what that's going to look like down the road. I think that's the crux of sustainability.
Veronica - 00:19:37:
It is. And to your point. One is the crux of sustainability. Two, we need to pay attention to these lessons learned. And you're right. We don't have a good diversity amongst our physicians because structures were put into place that prevented that. We don't have certain practice types. We don't have as many midwives in practice because structures were put into place and processes that prevented that. We have structures that are being put into place now around the Dobbs decision. And if we don't pay attention and learn from the things that have happened in the past around the structures, we're going to be looking 10 years down the road and we're going to say, why don't we have any medical students going into OBGYN? We already know that by 2030, we're going to be short 5,000 OBGYNs. And now we have something that the data has shown that there are fewer medical students choosing to go into OBGYN. And for all residency programs, I just talked about this with someone from the AMA, for all residency programs in states that have stricter abortion laws, there are less applicants applying to those states for all specialties. So again, thinking about structure, process, outcome, and culture, because that's a part of it too, we have to learn from the lessons of bad structures that have given us the outcomes, that we're now trying to recover from.
Christie - 00:21:06:
I think that that's a really nuanced view that is very hard in the moment when you're providing care at the bedside, right? It's well and good for me to sit here in an office in Washington, D.C., and to say all of this. And I know that when I was at the bedside, it was very hard to tie things back. And I think that's an important piece of the equity work that we're doing, that people are bigger than. Than what you see in front of you, right? That they come with all of those pieces and parts. And the healthcare system does as well. I got a degree in policy because I wanted to do work in that and then very quickly didn't care as much for policy when I was done with it. Because it can be really distressing to see the complexity in these spaces, which is one of the reasons I think you and I both are attracted to quality models and the continuous nature of them because we recognize the difference they can make. And I think that helps with fatigue, right?
Veronica - 00:21:59:
Absolutely. I mean, and to your point, I think, and I've said before, I think it's so important for anybody that is in health care, they don't have to go and get a degree in it, but have some experience in public health. Because it forces you to start looking beyond that patient that's right there in front of you and start thinking about the bigger landscape. And when you think about the bigger landscape, it actually is still helping that patient that's in front of you, because then you're able to understand, well, this patient may be a step behind because of these social drivers of health that you would not necessarily pay attention to if you didn't have a public health lens. And I think when we think about quality and we think about equity, you cannot, focus on either of those things if you're not thinking about it through a public health lens.
Christie - 00:22:50:
You know, collaborative care models, we're talking about midwifery, we're talking about different birth locations and birth settings. We're talking about reimbursement. We use collaboration as a buzzword and to describe a lot of different things. I'd like to talk about that a little bit with you. When I say collaboration in this context, what are your thoughts? Where do you first go with it?
Veronica - 00:23:12:
First place I go, and this is because of some other work that I'm doing, is to your point, there is not a shared definition. There's not. I mean, art has a definition. There's all these different organizations that have definition, but we're all interpreting it a different way, and which is really the most important part of collaboration is to make sure we got to all be speaking the same language. I mean, the same thing. For me, collaborative care means that we are all working together toward a common goal. And that common goal being for that patient and being advocates for that patient, doing what we need to do within our lanes, outside our lanes together to help that patient to get to the patient's goal, which is in general a healthy outcome.
Christie - 00:24:05:
And I think that's important. The point you just made there that you may or may not have made on purpose, the goal is not necessarily what we want it to be. I mean, generally they're shared. We want people to be healthy and thrive and the families want that too. We don't ask patients sometimes what their goal is. We make a lot of assumptions and those assumptions come through the lens of our own biases and experiences. That was a real learning point for me that I wish I'd had 20 years ago in my career. When we talk about patient-centered care, it's not just that we talk to the patient and get their input. It's truly putting them foundationally in the center of what's happening. And again, it's another one of those definition things. So we've talked about how words matter in multiple podcasts together. But I think the centeredness of those goals should be the center of the collaboration because then it doesn't run to paradigms and egos and all of those pieces. It's again, like we want the same thing, which is what the patient wants. What does the patient want? And you go from there.
Veronica - 00:25:02:
100%. And it was intentional that I used that. I see it all the time in clinical care. I see it all the time with patients, again, switching from obstetrics, but just in the work that I do for patients that have fibroids. Where they are coming, a lot of times they're coming to me because they've been seen by other providers and they've been offered options, but no one ever asked the patient what they, what their goal was for treatment. Yes. You're as a, as you said, through your lens, which is biased, your goal may be to treat this patient's anemia. Okay. That's fine. But the patient's goal may be to treat the anemia, but preserve their fertility. You just, you have to find out what the patient's goal is. And when we say patients are non-compliant, which is a word I feel like should be just, we should just strike them from our language. The lack of compliance a lot of times is because there's a lack of buy-in on the patient's part because we never ask them what they needed. We never ask them what they wanted. We never ask them what their goal of care was. To your point, when we do that and then we're all the collaborative team is working towards that goal, then we are collaborating and not working towards my goal for the patient's care, not working towards the MFM's goal for the patient's care, not the doula's goal for the patient's care. But we're all working towards one goal, which is the one that's identified by the patient.
Christie - 00:26:33:
Sometimes patients don't even know they get to do that. Right? Like, it would never have occurred to me to express what I wanted out of treatment as I've gone through different treatments as a patient. And so that's where I think our responsibility might lie in the patient counseling. You know, we talk about, and you and I have had the same conversation, shared decision-making, informed decision-making, all of those pieces. You don't know what your goals are sometimes as a patient. And so like, what do you want? I don't know. What do you want? And this is a back and forth loop forever with your clinician. I think we need to build skills in that. I certainly do. I definitely don't feel like that was something that I was trained in or have seen training happen for medical students and resident physicians and other folks either about really getting to what is it you want or need from either this experience or this care.
Veronica - 00:27:23:
I do think in the time that I've been in practice, the 16 years I've been in practice and the 20 years of being a physician, I am finding while, yes, patients don't always know they have choices, I'm finding that there's a bit of a transition because social media is such a big thing. And a lot of times when I am talking to patients about choice, whether that be, you know, whether they want to have an epidural during labor or they want to labor in the tub or whatever the options are that I want to talk to them about, they know a lot of times they do know that they have options. They may not know all their options, but they know they have options because social media educated them that they have options, which is one of, I think, one of the benefits of, of, of social media. There's other things that I think are not so great, but I think that is one of the benefits. And that's very different than when I first started in, in, in practice. What I'm specifically thinking about a patient in menopause care. And she, the only resources she had at the time was what Oprah said on, on her show that day. Whereas now, I mean, there's, you know, patients come in and they have exposure to so much more. And so it is, society is making us as physicians really have to, in my opinion, to stop and think about how am I counseling my patient? Because my pain- Like it's, I don't hold all the, all the answers anymore. I don't have all the, I don't have all the power. My patient, I need to, I need to make sure I'm relinquishing some of that power to the patient as it should be because the patient is coming in more informed now.
Christie - 00:29:04:
Mm-hmm. Different expertise that all ends to the same goal as defined by the patient. I also think that, you know, understanding that goals can change is important. And I think we see that a lot in care teams where we have to redirect what we're doing or we have to pivot. I think that that requires more than one conversation with the patient.
Veronica - 00:29:23:
Oh, yes, absolutely. Absolutely. I think it requires more than one conversation. I think it requires and you may have been meaning it in a different way that I'm visualizing right now. And I'm thinking about a conversation that we had at one of our LAPC learning sessions because in the sub-statrix, a lot of times. Patients can have the best laid plans. We're going to do this. This is how it's going to go. You know, we have all of this. And then the baby decides, nope. That's not how it's going to happen. So the goal is still the same to have a healthy baby, but how we're getting there may be different. And it's really important to communicate why that shift needs to happen. And I know I've gotten some pushback before about, well, I mean, it's an emergency, so we just have to do what we have to do. No, it takes two seconds to stop, to talk to the patient, calm the patient down, or speak calmly to the patient to be able to inform them on why the plan needs to change and to get their permission to still change the plan.
Christie - 00:30:34:
Yeah, healthcare is not an awesome game at all costs, right? In general, I think we have more in common with our patients than we realize. And they have their own experiences that they bring to the table. And the things that worry them aren't always the things we understand are worrying them. I think of some of the examples we've talked about, too. I remember, I think it was last season, we talked about a patient who was worried about a fall or was worried about, and you were able to reassure her because she had sort of not an old wives' tale, but had then told things passed down about how harm could come. I think of that actually a lot because I think we even have that in our profession. Where, well, I had this patient and this thing happened. And we all as clinicians and bedside providers walk around with what I would say is actually some trauma of seeing rough stuff happen. We go into this because we want it to be wonderful. We want that so much. And sometimes things go sideways, as you referenced, and things have to change. And we cannot prevent all of the outcomes that go along with that. And so I think that that lens is there too. And acknowledging our own pieces and finding ways to maintain our wellness is also critical in how we communicate things to patients.
Veronica - 00:31:48:
I think that is huge. And quite honestly, that trauma is a lot of what we are now, tackling and trying to improve the relationships between midwives and physicians. In Louisiana, I'm sure it's the same in most states. It's, you know, I'm thinking of a physician in particular that had one bad experience. From a community birth. And now he thinks all of them are bad, you know, and, and same, same, I have midwives who have had that one physician really be, well, not collaborative, not professional. And so now they don't want to talk to any physician. And so it is really super, super important, like you said, that we acknowledge the trauma that we've experienced in the healthcare space so that we can be more open and, and not have stereotypes and biases based on those, those singular events. Also interesting, I attended a lecture about, about provider burnout. And this lecturer was just demonstrating that if you overlie trauma, physician trauma or provider trauma, not just physician nurses too, but provider trauma and burnout, that it's, it's an identical, like an identical graph. And so for lots of reasons, it's really important that as healthcare providers, we acknowledge and address the trauma that we've experienced in the, especially in the birth space.
Christie - 00:33:15:
Because you're not obligated to just carry it, right? There's a lot of, there are pieces and parts. I worked in critical care before coming to obstetrics and there was sort of an attitude at the time and it continues to evolve of like, yep, that happened, need to move on, next patient, you know, and obstetrics like critical care is a critical time period in people's lives and you see them at their most vulnerable, which is both an honor and can be incredibly painful. And I think keeping that patient focus is very hard to do when you can't hold that space around both of you because you have your own things coming up. As you're talking about the community birth piece, it's so incredibly human. I had one bad experience, I'm not gonna like it. I think about the marble jar, I've heard this talked about with trust. And when you're building trust with another person or profession or collaboration, you put a marble in every time there's a positive interaction. But when you have one negative one, it's like the jar hits the ground and breaks. And that's all it takes is one time. And I think about that a lot because I think about that through the lens of sort of the trust in the medical community from the patient side. But I do think it's interprofessional as well. You know, we built trust, we had positive interactions, but then that one time you wouldn't listen to me and I tried to tell you and right, it takes one time. And so I think about that. I also think about the paradigms that we come from. My clinical training does not align with your clinical training. If I'm going to be very honest, I'm a nurse by background and I learned nursing theory. I don't know what social work theory is. I don't know what physician medical theories, diagnosis theory. And we all do work in those paradigms of theory, whether we want to or not. We can roll our eyes at our theory classes we had to take. But the reality is those are made for a reason because they're representing and interpreting the way we actually function. And I think about that a lot because I recognize that a certified midwife or a nursing midwife or a nurse practitioner, physician, we're coming from really different paradigms. It doesn't matter that we have the same goal because we're trying to approach it so differently that we lose sight of that.
Veronica - 00:35:16:
Very, very, very, very true. And, you know... I think acknowledging that, understanding that helps you to open your perspective. But you're right. We have all been trained so very, very different. And we have. Not been trained to collaborate. I, in particular, my first time working with a midwife was probably, I'd been five, six, seven years into practice. And I'll be honest, I was not really open to that. I had no idea what to expect. I didn't even know we could work together, that collaboration was a thing. I just felt like, well, this is just another person on the unit that's delivering their patients, not understanding that it's meant to really, really be a collaborative model. We're just not trained to collaborate in that way.
Christie - 00:36:15:
So I was really spoiled. And where I first learned and trained in obstetrics, I worked on a unit where the midwives were helping train the resident physicians because they do have skills and an understanding of sort of supporting, I don't want to say normal birth because that's not the term we really should be using, but they respect the processes so much. And I didn't realize that wasn't the norm. That was my own bias. So I think that's really important to recognize and to call out because different regions, different facilities, different academic settings have different folks training from very different paradigms. Even family medicine versus obstetric medicine have very different training paradigms and frameworks. Do you know, I think I just mentioned one, but are there other ways to bridge across those paradigms?
Veronica - 00:37:06:
Well, I think the answer is yes. I do think it is. Important. You mentioned just now, it's something that I've mentioned before. I think Integrated residency programs that have midwives that are training with residents and medical students in academic centers, I think is a really important avenue for creating that collaborative care model. As I mentioned, for me, I did. That's not how my residency program worked. So then if you imagine now I've been trained in this way of not working with midwives and now I'm out in practice. Now, I will say I'm an early adopter. So I was like, okay, we're going to work with midwives and we'll figure it out. But that's not the usual. So, you know, if that's not if that's not how you've been trained, it's very difficult to then come in. This is this is change management. What we do in quality improvement is difficult to get change from how from their comfort zone and your comfort zone is how you were trained. And so I think integrated training programs, I think, are very important as we think about our the future doctors. Like, I'm not going to be doing this for forever. There are other doctors that are going to be taking over and continuing this work. For them to get trained in that way, I really think that that would help this collaborative care model.
Christie - 00:38:31:
I think it's also, if you're going to talk QI, it's the other pieces of change management. It's the same shared language. It's respect, understanding of roles, you know, really having the same goals and discussing those goals. And I think when I list those things off, I think one of the sort of incubators of that is drills and simulation. Of course, I think that because I'm a quality person. But that was where I gained an understanding. For emergencies. And it was so interesting to be assigned the clinician role. And have to be the person making the calls during the mock code. Good Lord, that's overwhelming. There's a lot of people talking. I had a whole new respect for the physicians that I was working with. And that was just like advanced cardiac life support. And the ACLS training, it gave me a new understanding of making eye contact, of making sure I was being very clear, of making sure I mentioned things that were in my head that might not be in theirs. I do think there's something to be gained there if you can start from a place of mutual respect.
Veronica - 00:39:26:
Absolutely. And to that point, not that they're going to be taking over, being in each other's roles. Part of our community birth initiative is doing regional trainings between physicians from the hospital, midwives, emergency room providers and a group that we commonly leave out, EMS providers as well. And it's creating the collaborative team model, the teamwork so that we have respect, but also so that everybody understands each other's role, because that's once you understand the other individual's roles. I think that also leads to your point to that respect. I respect a midwife's ability to support physiologic birth because the midwife was trained in a way I was not trained. I will say I'm over here now trying to figure out, well, how do I put my patient and welfares. And what was that? What was that called? What was that position? The flying cowboy? Because that's not something I was trained in. But I like I've seen it work. I know it works. So I think you do gain that respect when you understand what that person knows and how they contribute to the care in a way that you are not able to because you don't have that knowledge base.
Christie - 00:40:40:
I think that brings us to, we're talking about flipping roles.
Veronica - 00:40:44:
Yes.
Christie - 00:40:46:
So this has been the season of the one thing. So I'm going to open the door. And do you have any questions for me in general or specifically?
Veronica - 00:40:55:
I have a specific question for you. What is your one thing? It was so hard for me to answer that question. One, because I am a woman of a lot of words, but just to have just one thing that was so hard to narrow it down. So I'm gonna flip the table and I'm gonna ask you, what is your one thing?
Christie - 00:41:15:
Yeah, that's really hard. I realized when I started thinking about it, I've asked people, la la la, and thought that they could just whip it out. And I've talked about a lot of the things that I think are fundamental even today. And I know they're a little bit redundant, but I don't think we can say them too much. I think the one thing is start where you are. I- Years ago, remember mentioning checklists to a nurse manager because our floor didn't have them. This was before checklists were really coming out. Like it was well before that. But I like, there's got to be something we can do. And I think most of us know that feeling in different areas of our lives, but definitely in clinical care. There's got to be something we can do. There is. There almost always is, even if it's just meeting a patient where they're at that day or holding the space for them or taking those two minutes you described. But it's start where you are. And this is long, hard work, but there's so much joy in it. The reality is that more good things happen in the spaces we work than bad things and that people are going to get amazing care in family-centered models. The fact that there are so many people I can call and be like, hi, do you want to talk to me on a podcast? And they go, I've never done a podcast before, but okay. People have been so brave because they care about this work. Whenever I'm at a maternal child health conference of any kind, I always sit there and. Again, I'm a little bit of a geek and a woman of many words, much like yourself. But I look around and I think about all of these people that have this shared goal of we're here for a reason. We're not here recreationally. We're talking about equity. We're talking about Black maternal health. We're talking about things that for many, many years weren't talked about, weren't believed, weren't listened to. We're not going to get it right. Every time when you start where you are, you're not going to get it right. And it's doing that next right thing and understanding that those seeds that you're sowing, like we talked about earlier, are the roots that are going to go down and grow the next thing. So I think if that was my one thing, I would say start where you are.
Veronica - 00:43:08:
And I am going to remember that. I'm going to remember that. We talk about it a lot in equity work about meeting people where they are, but it is applicable really to any of the quality improvement work. And it inspires me to see it through your eyes of being in a, cause I'm at a conference now, but being at a conference where people have given up their time. They've given up their time from work. Some of them given up pay to be here, for this shared goal. And it makes me really hopeful that when the next generation of physicians come to replace me, that maternal health is going to be in such a better space.
Christie - 00:43:51:
I think that's the dream we're both working for. So next season, who knows when you'll pop up again? I feel like that's going to be a repeated theme. I can't let you get away. The next season of the AIM for a Safer Birth podcast, brace yourself. We're going to talk about data. But data is a good thing. Data gets us where we need to be. It tells us what we're not doing. It tells us what we are doing. We're data geeks, a little bit, both you and I, I think. But because we know data can make change and can show us what we're doing right or wrong and the unintended versus intended outcomes. So stay tuned for that. And I swear I'm going to find a way to get Dr. Gillispie-Bell back here for it.
Veronica - 00:44:32:
And if this is a reason to bring me back or any other reason, I have to just share, I was at the NMA, the National Medical Association conference a few, a couple of weeks ago when Mike Bloomberg was there and gave the enormous gift to the historically Black colleges and medical schools, the HBCU medical schools. And he said. They believe in the Bloomberg philanthropy that in God we trust, everybody else bring data. And so I said, you know, I put that in my little list of quotes to remember.
Christie - 00:45:11:
And that very well might be one of the names of the podcast. Well, thank you again for joining me today and the multiple times that you've joined to help us wrap up season two. I loved having you as always.
Veronica - 00:45:27:
I love being here and always love talking to you, Christie.
Christie - 00:45:35:
Thanks for tuning in to AIM for Safer Birth. If you like the show, be sure to follow wherever you get your podcasts so you don't miss an episode. And to get involved in work related to addressing maternal mortality, be sure to check out the Alliance for Innovation on Maternal Health at saferbirth.org. Together, we can work towards safer birth and healthier outcomes for all families. I'm Christie Allen, and I'll talk with you next time on AIM for Safer Birth.