Of all the recent professional upheavals I've survived recently, there is one which has posed a particular barrier to writing this blog: my departure from childbirth services. You heard that correctly--I'm no longer attending births. Doing so has been such a huge part of my professional identity, and my identity as the writer of this blog, that it has been really difficult for me to talk about the change without succumbing to despair. Today I feel ready to blurt out the truth, and I hope this will release some of the inhibition I've experienced in my writing.
I knew my participation in maternity care would be diminished after my departure from Gimbels. The Birth Center there is predominantly run by family doctors and is, as I have described in the Birth Stories, a uniquely tolerant environment for women to have their babies. Unfortunately, the environment at Macy's and Nordstrom is closer to the standard obstetrical norm: run by OB-GYNs supervising CNMs, unfriendly towards extending privileges to FPs, surgically oriented, and regressive in birth policies (i.e. no VBACs, no water birth, an emphasis upon spinal anesthesia for labor relief, etc.)--so working at these new hospitals meant a significant paradigm shift if I were to pursue childbirth privileges.
The chief medical officer at Macy's is a friend of mine, and would have supported my application for privileges at the Labor and Delivery unit. Two of the older OB-GYNs would have been glad for the help in their laborist pool, but they also had the ulterior motive of wanting me to work for them in their so-called "primary care" practice, which would have consisted of providing preventative care services (Pap smears, mammogram referrals, GI referrals, screening labs) to well-insured patients, perhaps managing simple chronic illnesses (hypertension, dyslipidemia), but referring all the messier aspects of real primary care--pain management, mood disorders--back to the already-overburdened rural health care system. The unspoken understanding is that I would keep the referrals for these well-compensated preventative services within Macy's and its satellite services. The truth was that this "primary care" practice was nothing more than a venue for cherry-picking revenue-generating opportunities from the true spectrum of primary care, and I didn't want to have anything to do with it.
Even though I was tempted to apply for childbirth privileges at Macy's just to piss everyone off and shake the political tree, I finally decided this was a lousy use of my psychic and creative energies. I'd had enough confrontations with the administration of Gimbels and the band of incompetents running Xpress Hospitalists during the past year and didn't feel like rolling up my sleeves for any new ones.
The other alternative was to continue delivering babies at Gimbels, but the logistics of this option proved overwhelming. How was I supposed to be a contributing member of the OB call pool there if I was spending a week at a time at Nordstrom, over an hour's drive away, and another week of night shifts at Macy's? How was I supposed to provide prenatal care at my clinic? Sure, I could be on call and at clinic on my off days, but then this put me back into the category of Doctors Who Work All The Time. I used to be one of these doctors who never take a day off, who is committed to work twenty-seven days every month--hell, I even enjoyed the experience, but since Noo's illness I don't feel I can drop everything and run to the hospital to catch a baby all the time.
Dropping hospitalist work and providing prenatal care full-time was not an economically feasible option at the FQHC practice where I used to be based. I was paid $400/day to see 20+ patients in clinic, and $100/night on call. If I was lucky enough to attend a birth, I was paid $300; however, if the labor concluded in a C-section, I was paid $100 to assist the surgeon. These fees applied to quick labors and week-long inductions alike. In the case of a multi-day labor or induction, I might earn less for attending the resulting birth than I would in a day of clinic. Of course, if I missed a clinic to be present at a birth, I lost the $400/day I was counting on for being scheduled to work that day. Certainly I could have made a living on the basis of these numbers, but just barely, and at the expense of going back to working almost every day of the month. Meanwhile the size of the living I have to earn has increased noticeably since Noo's illness, and as I mentioned above, so has the importance of balance work and time off.
Finally, and most important of all, I haven't had the emotional energy to give to being fully present at a woman's labor since Noo's illness. I believe emotional presence is essential in a birth attendant, and I don't want to rob a woman of that presence during her labor. Even though I've been emerging from the Mighty Blue Funk which has oppressed the past six months, I haven't felt the return of that broad streak of courage, humor, and tolerance for the unknown which used to be my greatest asset in the labor room, and I won't go back without it.
I don't know what the future will bring, if I will return to the practice of maternity care I used to love so much. The risk of letting the practice lapse is that I might lose the ability to keep privileges at a hospital where I might be of service, but the benefit--for now--is a bit more sanity, a reasonable pace of life, and more time to recover and awaken to this new life.