As promised, here is an interview with Dr. Jim Betoni and Camilla Bicknell, authors of The Pregnancy Power Workbook. I think this will make it clear why I called them a week later and asked if they wanted to work together and why I think their workbook should be used far and wide.
You are both working in busy practices. What made you decide to dedicate your (lack of) extra time to write this workbook?
Camilla: The busy practice setting inspired the question, “Do you think our patients know what questions to ask”. When in the exam room I usually ask, “Do you have any questions? The answer is usually “no”. I truly believe the answer is probably “yes”, but the woman doesn’t know what she needs to know or what questions to ask. She may think, “if it’s really important, my provider will tell me what I need to know”. Or even, “they seem so busy, I’d hate to bother them with such a basic question.” With these concerns, Jim and I decided we would write a workbook full of basic pregnancy questions. Questions that would allow women the opportunity to learn at their own pace.
Jim: For me it was the true sadness the came about when patients would come in with a bad outcome with something that could have been prevented with a little knowledge, especially fetal kick counts and the patient waiting days to call the office then presenting with a fetal demise. Or when diabetics don’t prepare and get pregnant with their sugars out of control and increase their risk of birth defects markedly.
Why did you choose the workbook format?
Camilla: We recognized there had to be a better way of getting information into pregnant women’s brains. There are no Pregnancy Workbook style guidebooks on the market. There are many traditional pregnancy guides on the market that offer massive amounts of comprehensive data, but the information lacks a structure that assures even a basic level of understanding. The interactive format found in our workbook transforms this pregnancy information into practical pregnancy knowledge. Armed with this knowledge, women have the opportunity to catapult themselves from uninformed (frequently overwhelmed) individuals into empowered pregnancy experts. Workbooks are proven methods for learning. When forced to write something down, our brains have the best chances for remembering.
Jim: I know my story is boring by my 7th grade homeroom teacher (who was my 8/9th grade French teacher) was the best teacher I’ve ever had and her tricks I use on my kids. When she wanted us to learn something she would do several things, such as make us write it 5-10 times and always made us look up words. She said “if I tell you then you won’t remember it but if you actively look it up you will.” Our book actively makes patients look things up… and write things down, and thereby helps them remember. (P.S. We are still friends and now my kids call her son—who is 31—“uncle.”)
Who do you hope will read Pregnancy Power?
Camilla: If I had to narrow it down, ideally it would be read by any woman contemplating/planning a pregnancy. Pre-conceptual knowledge is powerful as it relates to changes in health, nutrition, and lifestyle. But since we know that nearly 50% of women become pregnant without planning, I would hope those who have the least support from friends or family, or those with limited healthcare resources would read The Pregnancy Power Workbook. The workbook provides an “action plan” that helps these individuals gain some control. As their knowledge grows, they have the opportunity to enjoy more informed and rewarding pregnancies.
Jim: I hope everyone who wants to get pregnant or is pregnant or TEACHES about pregnancy will read it. I have learned working with OB-GYN residents that you would be surprised how much they DON’T know about common questions their patients will ask, like can I dye my hair?
How did you become interested in women’s health, particularly pregnancy, birth and postpartum care?
Camilla: As a member of the nursing profession, we are trained to educate our patients. I gravitated in my career towards women’s health and the pregnancy spectrum because of the willingness and eagerness of these patients to learn. A captive audience for what I have as a particularly good knack— I love to teach. The time around a woman’s pregnancy begins the next chapter of her life. If I can contribute to a woman’s confidence and empowerment throughout her pregnancy and add a positive influence during this miraculous time, then I’m happy.
Jim: I was actually always interested in high risk pregnancy. Unfortunately living with an only sibling who has a birth defect changes your perspective on life and I saw the pain (and happiness) my parents went through and hope that my personal experience will translate into knowledge for patients
How do you talk to you patients about risk, particularly those with limited health literacy?
Camilla: When I’m talking to any patient (limited health literacy or not), I try to frame the information in a question/answer format (similar to our book). I keep narrowing it down so she actually recognizes the potential risk on her own…many times I can actually see the “light bulb” coming on. Then to follow up, I’ll say something like, “Tell me in your words how his new piece of knowledge may help your pregnancy,” or “Tell me how this makes sense to you,” or “Tell me what you could do different to limit your risk of diabetes (for example)”.
Jim: Rather than lecturing to a patient I too try to get enough accurate information to patients so they can figure it out for themselves. I am fortunate as an MFM that I actually get more time with a patient and her family. I tend to “give the facts” and base the facts on recent articles. I print the articles and let them take it home to read and digest at their own pace. At the next appointment we again review the issue and give the patient more time to ask questions and learn.
Jim, now that you’re in Maternal Fetal Medicine and regularly seeing high-risk patients, have you found that your approach or philosophies have changed?
Jim: Yes my approach has changed. Again, I get more time with each patient. This gives me the chance to spend time on details that are “evidenced” based vs. “anecdotal” based. When a patient is referred to me they are there for a specific problem versus “the whole pregnancy”. The patient’s routine OB provider has the more difficult job of trying to put it all together in the whole pregnancy. I love the opportunity to spend time in the most current literature and practice the most up to date high-risk care for my patients. Philosophically, I still wish we in OB could all spend more time, but it isn’t reality.
What have been the overarching trends in communication with patients, the provider-patient relationship and the patient experience over the last couple of decades?
Camilla: A few things….providers have got to get away from “teaching” and gear their care towards “facilitating”. When I say facilitate, that is, creating an environment that allows patients the opportunity to share what they know and don’t know…but recognize many patients don’t know what they know or don’t know. There has been a disconnect with the explosion of the Internet. When a patient says, “I read this on the Internet”…many providers immediately say, “Yeah, there’s lots of information out there…but there’s no way of knowing if the info is good or bad” (which ends the conversation). Wouldn’t it be better to have a list of “recommended” web sites that do offer consistent and accurate info and suggest they explore any “mixed messages” at their next appointments? If a patient felt they were getting everything they need from the provider (which is virtually impossible) they wouldn’t go to the Internet in the first place.
Maybe looking beyond traditional exam rooms could help. Many patients are conditioned to being passive in the exam room. “Wow…this is the doctor….I don’t know nearly as much as they do, I don’t want to bother them with dumb questions”….thus I’ll ask my mom or friends.” So many times I have women tell me, “my friends have said__________.” When dispelling a myth (or misunderstanding of the health system) it is amazing that they will believe their friends rather than their care provider. That tells us…we in health care are not doing as much as we should for communication. Another huge thing is technology. Patients confuse “I get an ultrasound at nearly every appointment” with good quality care. They are so focused on the ultrasound, they haven’t heard any of the teaching or felt the benefits of their provider. Getting an ultrasound is “good care” in their minds. Sadly… they think that all is good if the ultrasound is done. Granted, ultrasounds are fun, real, joyful, and sometimes reassuring, but they do not mean “quality.”
Jim: Sadly, communication has deteriorated because of the lack of time allowed for every patient. With group practices today, it is rare for a woman to see the same provider throughout her care and then have that provider deliver her baby. It is a sign of the times.
Where do you think this workbook fits in in the movement toward patient-centered medicine, informed choice and shared decision-making?
Camilla: Until this workbook there has never been a system that assures women have even the most basic of understanding of preconception, conception, and pregnancy. Many times it feels like the necessary learning is done “after the fact” rather than in anticipation. Women must learn to accept the responsibility from day one if they want to be 100% involved, patient centered, and with shared decision making.
Sadly, many women don’t know they have the opportunity for informed choices because they don’t know what the choices are. Many times providers of care feel overwhelmed just squeaking by (time wise) doing the basics. That’s reality of health care in America. So….the workbook offers something new. It’s a totally (totally) new way to learn about pregnancy. The structure of the workbook assures a higher level of understanding.
Armed with the necessary knowledge, women have the opportunity to take their prenatal care to a whole new level. They actually can become pregnancy experts. Once women have this empowerment (and knowledge), the time in an exam room can be better utilized towards that individual patient’s needs (patient-centered, shared decision-making, etc). If a woman doesn’t have the empowerment, the frustration grows at every appointment…as the overwhelming need for cramming everything in takes over. There is no higher level or individualization.
Jim: When a woman who is pregnant actually does her workbook “homework” she builds her level of knowledge to a much higher level. The consistent level of knowledge found in the workbook also holds her provider to a higher standard. All pregnancies essentially start the same and all need the same baseline level of knowledge. After that baseline or foundation is built…the differences in the pregnancies come out…Is there diabetes? Are there twins? Do they want a VBAC? Do they have a birth defect? Are they a single mom without support? Are they a victim of violence? Do they take medications?…on and on. With a good foundation, the providers of care will have a greater opportunity to move towards patient-centered medicine with informed choice and shared decision-making.
I received a free copy of this book to review.