Transitioning to Practice
Each practice group is unique; they vary in everything from how they organize themselves in clinical practice, their culture and dynamics, how decisions are made and how they function as a business. Hospital culture and community culture can also vary and influence how practice groups engage with each other, their colleagues, and their clients. Here are some things to consider as you transition into working at a midwifery practice group.
Start at the Beginning
A practice group’s history may inform their values, approach, and how they manage clinical, business, and professional situations. As a new member of the practice group, it is helpful not only to understand its present state, but also the context in which it evolved. This may help you to better understand the reasons for existing approaches or philosophies and make it easier, should you happen to question any of those approaches or philosophies, to know how to approach asking about possible changes.
Practice groups generally find their start when the need for services in a community justifies the funding of midwifery and coincides with the availability of midwives to meet that need and establish the practice group. In the early years of a practice group, the demands of starting up a small business while fulfilling clinical responsibilities and managing extra-professional obligations are incredibly challenging.
Trained as clinicians, rather than businesspeople, it can be overwhelming to learn how to develop budgets, hire staff, find clinic space, set-up telecommunication systems, manage payrolls, navigate leases, integrate into a new hospital, decide which computer systems to use to manage finances, clients and charts, and develop and manage partnership agreements. For some practice groups this can result in strategic decisions, like the development of a clear vision, goals, and culture, being delayed in favour of more practical concerns.
Regardless, over time, these elements of a practice group’s culture will become established, implicitly or explicitly. To help midwives develop and maintain healthy workplaces, the AOM organizes regular professional development and resources on the topic.
If the elements of a practice group’s culture are explicitly stated in written form, this can make your understanding of whether they are a good fit much simpler. There are opportunities for midwives and their practice groups to evolve and develop together, but it can be much easier to know if a practice will be a good fit, if you take the time to learn about common values, goals, and culture when you are thinking of joining a practice group. If you find these pieces aren’t explicitly stated, you can try to tease out whether there are informal goals, expectations, and values that guide the practice group, even if they aren’t written.
Question your Assumptions and Understand the Rationale
It can be useful to remind yourself of your own biases, assumptions, and interpretations and to be aware of them when interpreting the actions and intentions of others. When a policy or action affects us, we may reach assumptions about the intention behind the action and those assumptions may be influenced by the effect that it had on us. If the policy or action is not explicitly explained to us this can add to the misinterpretation. When we don’t stop to check if our assumptions are correct, we can react based on our assumptions and thus misunderstandings can escalate. If we work to seek an understanding of the rationale behind the policy or action we often come to appreciate the intention behind it.
For example, some practice groups assign one person the responsibility of allocating clients to midwives. The effect of this approach may be that midwives can’t choose the clients they feel most attached to. If a new midwife assumes that the intention behind this approach was to control them and reacts accordingly, there is a potential for conflict to arise. If they speak to the practice group about their perspective and the policy’s effect on them and asks about the policy’s history, they may learn that there is good reason behind it. For example, some rural practice groups use this kind of a policy to fairly share hospital and home births and assign clients to midwives that live in the same part of a geographically large catchment area.
Structures, Roles and Responsibilities
Some practice groups have formalized structures of partnerships and specified roles that midwives take with respect to addressing specific business, clinical, or professional issues. Other practice groups have very informal roles and processes. Depending on the nature of the control over how work is done in a practice group, a power imbalance can develop or be perceived to exist and can cause tension between midwives.
It can be helpful if, before you join a practice group, you determine when and how issues are raised, who participates in making decisions, how clinical, professional, and business responsibilities are shared, and how midwives may be compensated for clinical and non-clinical work.
The AOM often hears from midwives who don’t understand how decisions are made or how compensation is allocated, and it may appear unjust. For example, the AOM On-Call line has received calls from midwives in practice groups where compensation is tied directly to births attended. This may result in a midwife who is leaving the practice not being compensated for the care provided to women who deliver after she has left the practice group. For these midwives, this seemed unfair until they understood, from reviewing a clearly written contract or speaking to the partners, that they had benefited from this policy when they started at the practice with an established caseload. Because other midwives had provided the prenatal care, they had not had to build up their own caseload, waiting months for a billable course of care, at the beginning of their contract. Similarly, they were not being paid out in arrears after the end of their contract.
The simplest way for a practice group to avoid misunderstandings and communicate how it functions is to have a written agreement or protocol outlining all of these issues clearly. Knowing what is expected provides an opportunity for understanding, for negotiation if required, and for determining if the practice group’s approaches are a good fit for your needs. This agreement, combined with a clear understanding of the nature of the TPA-Practice Group Funding Agreement, and their impact on practice group functioning and individual member’s choices and options within the practice group will provide clarity and protection for all parties working together in a practice group.
Twice annually the AOM organizes Business Practices Days, which provide an opportunity to learn about the management of a midwifery practice group. These can be very helpful in understanding what is happening “behind the scenes”. Click on "Education & Events" to see if one is scheduled near your community.
Partners and Associates
AOM lawyers have warned that there is a risk that long-term associate midwives may be seen as employees. To mitigate this risk, they recommend that long-term associates become partners. Midwives who remain long-term associates in a practice group risk being viewed by the government as employees which means that they can’t claim any business deductions on their personal income tax returns and they are at risk of having to pay additional income tax for years where they claimed these deductions. Partners who contract long-term associates are at risk of being viewed by the government as employers and being held responsible for not having paid over-time and statutory holidays or having submitted deductions at source for their Canada Pension and Employment Insurance.
The risks are balanced such that neither partners, nor long-term associates, have a vested interest in continuing such a relationship for any length of time. When there continues to remain a separation between partners and long-term associates, both partners and associates are put at risk. Sometimes this is because founding partners, who have invested their time, energy, and money into the practice group, are hesitant to share it with others. Some associate midwives have found it helpful to understand this perspective and, in discussions about partnership, communicate their understanding while also recognizing that partnership protects BOTH the individual midwife and the practice group.
Developing a partnership model that serves the needs of all of the various midwives in the practice group can be a valuable part of the process of developing a healthy culture. There are many different models of partnership that may allow a new midwife to play a smaller role in the practice group, such as a silent, junior, or nominal partner, but still be invested in its success.
To clarify roles and expectations and minimize the risk to partners and long term associates, some practice groups describe their process for transitioning from an associate to a partner in agreements and policies.
- Written agreements, protocols, orientation plans, goals, vision, and mission statements will provide you with the clearest view of the community you are walking into;
- Where written descriptions aren’t available, try to tease out expectations around clinical, business, and administrative duties and how the practice group is organized and reaches decisions;
- Understand the MPG - TPA Funding Agreement and the history of the practice group and its protocols and approaches; and
- Check your assumptions and clarify rationale and intentions when you find yourself in a situation in which an action, approach, or protocol has an impact on you.
In the end, there will likely be unique situations which have not have been captured here and in those instances, the AOM can be a resource with tools that have been created to help practice groups build healthy infrastructure, with continuing education programs aimed at providing midwives with business and administrative skills they may not have learned as students, and with direct member support available at the AOM.