By Stephanie Tillman, CNM, MSN

September marks the start of first midwife jobs for many new graduates. Do you find yourself stepping out of the exam room to check Up-to-Date, call a colleague, or email a classmate? You aren't the only one! Here are a few strategies to help you double-check your instincts smoothly.

The first few days, weeks, and months at my job (now over one year ago!) were tough – and by tough, I mean mentally and emotionally exhausting. It was partly because I was nervous to care for women again after taking 6 months away from direct care to deal with graduating, moving, and credentialing paperwork, but it was also partly because my midwifery status was official. I was on my own with no one responsible to check my work, to assure me I was doing okay or that I was missing something. The realization that the responsibility was all my own was a shock to my system.

I felt overwhelmed reading the schedule and each patient's associated complaints, especially when they included what seemed to be vague symptoms like general pelvic pain, irregular menses, or itching. What could it be? How would I be able to help? What if I didn't know what to do? Of course, there were often other providers to ask, and another midwife could be just a phone call away, but conferring with colleagues is not always feasible for every patient concern or question or uncertainty. Sometimes, after collecting a patient’s history, I needed to step out of the room to check my resources. Here are some exit strategies I've used to get a moment alone while reassuring my patients:

• New evidence has just been published on that topic. Let me review the latest recommendations and I'll be right back to discuss those with you.
• Let's rule out a pregnancy or a strong urine infection: let me get you a cup and I'll be back in a few minutes to go over the results and the best plan forward.
• I have had a few patients with this problem and I have been trying a few strategies to help. I am going to double check for the approach that would be best for you.
• I work with a midwife who has helped many women with this lately. Let me chat with her for a second and I'll be right back.
• The truth is always an option! I want to make sure I'm giving you the best care possible. I need a minute to check a few resources, and I'll be right back.

I'll spend the time connecting with midwife colleagues, fellow practitioners, online and book resources, or asking other providers what labs they would like done if I know I'll be sending the patient their way. When a referral is the plan, I will let my patient know that I will still get her baseline labs started today and handle the immediate as well as possible. Eventually, you’ll view vague symptoms with the knowledge that there are a limited number of likely answers – and you do know most of them! Just give yourself some time.

And what about referrals to specialists? I could have used more classroom discussion about the process: when to refer, to whom to refer and why, and how to be a good referring provider. My learning curve involved a lot of trial and error, including direct phone calls from irritated providers, patients being sent back for follow-ups before their referral, and subtle hints in imaging reports like 'consider this...' next management step instead of a referral to begin with. Be patient with yourself and with the specialists. Keep in mind that it's not a perfect system, and you all have the goal of giving the patient the best care.

Do not diminish yourself or the profession of midwifery by saying, as I did once, to my horror, "I am just a midwife." Nope. Nuh uh. No way. You've worked too hard and believe in midwifery too much to do that to yourself or the rest of us. Some alternative, graceful ways to phrase the need for a specialist include:

• I am a midwife and I specialize in normal. I want you to receive the best care, and that is why I am referring you to someone who specializes in the issue that you and I are having trouble resolving.
• I am a midwife and part of my training involves knowing when to seek others' expertise. I think it's time for us to do just that.
• I am a midwife, and I work on a team with many excellent providers. We will all be working together to find the best way forward with you.
• Success should always be recognized! I am a midwife, and I am so glad we figured this out together. Keep me in mind for all of your women's health needs!

What advice do you have for new graduates starting in practice and needing a few minutes to garner resources? Any specific phrases or tactics you would use to keep the patient's confidence and allow the midwife a few minutes of time to collect their thoughts? Leave them in the comments below!