MANAGED CARE
The Nurse Is In
Nurses are stepping to the fore as the result of a breakthrough agreement between one of the nation's leading managed care companies and a major hospital, reports Ron Winslow in the
Wall Street Journal. The agreement gives nurse practitioners primary-care responsibilities usually reserved for physicians, and the nurses will be paid at physician rates.
Under a contract with Columbia Presbyterian Medical Center, in New York, members of some health plans of Oxford Health Plans Inc., of Norwalk, CT, may choose a nurse-practitioner instead of a physician as their primary-care provider, responsible for initial diagnosis and referrals to specialists. The nurses will work closely with doctors at Columbia and refer patients to them when necessary, but they will have unusually broad authority, including the ability to admit patients to the hospital and to write prescriptions. The managed care companies will pay the same rates, whether a patient is seen by a nurse or a doctor.
About 20 nurse practitioners will be involved in the pilot project, which could be expanded if results show that patients treated by the nurses fare as well as patients treated by physicians. Nurse practitioners have master's degree training in a medical area such as family medicine or pediatrics in addition to four years' nursing education. About 100,000 nurses in the United States have such advanced training.
Proponents of the program assert that the nurses' emphasis on education and prevention will help lower healthcare costs. According to Mary Mundinger, dean of the College of Nursing at Columbia and originator of the new program, "We're going to be marketing that we [nurses] are the prevention and health promotion specialists." She adds that the nurses are not out to compete with doctors, but will be a valuable addition to Columbia's medical services.
Others see it differently. Physicians, already under pressure from managed care, may see the takeover of a role usually reserved for doctors as unwelcome competition. "There's an extraordinary difference in the training a nurse practitioner gets and a physician gets, in duration, intensity, and type of training," says Nancy Dickey, MD, a family physician and chairman of the board of trustees of the American Medical Association. Dickey said that some studies suggest that nurse practitioners have to refer more cases to specialists than physicians do, thus losing any efficiencies that may exist to begin with.
One question yet unanswered is whether patients will choose a nurse-practitioner rather than a doctor to handle basic medical problems. If they do, Oxford and Columbia's agreement could have broad implications nationwide for HMOs, physicians, and nurses.
PATIENT SATISFACTION
Wanted: A Little Sensitivity
The results of what its sponsors say is "the largest patient satisfaction survey ever conducted" indicate that concern, empathy, and respect are the factors most closely linked to patient satisfaction and the likelihood that a patient would recommend a hospital to others.
The recent survey of more than a million patients showed that staff sensitivity to the personal stress of illness or injury and hospitalization, respect for the patient's condition and privacy, and response to the patient's need to be kept informed ranked in the top 10 as factors in patient satisfaction. Other top-10 factors included a cheerful atmosphere, nurses' technical skill and friendliness, and attention to patients' personal needs.
Press, Ganey Associates, Inc., a healthcare satisfaction measurement firm, conducted the survey from December 1995 to November 1996. The firm analyzed 1,007,612 patient surveys from 545 hospitals in 44 states. The survey included 49 standard questions on admissions, nursing, physicians, tests and procedures, food, rooms, family concerns, and other aspects of a hospital stay.
The survey confirms that interpersonal issues play a central role in overall patient satisfaction. Many hospitals have focused on "hotel services"--food, room temperature, and noise level--but these did not prove to be as important to patients. "Patients expect less of hospital food and accommodations and do not allow dissatisfaction with these areas to mask the importance of other issues. In other words, patients will make do' with marginal amenities, but not with impersonal or insensitive care," explains Rodney F. Ganey, PhD, codirector of Press, Ganey.
It may be more difficult to instill empathy among employees than to deliver a hot meal, but the survey suggests this is what management should strive to do. Patients respond positively to an understanding of the social and emotional responses that a hospital stay evokes.
VIOLENCE PREVENTION
Wounded Teens Persuade Peers
Teenagers, notorious for their resistance to good advice, will listen to antiviolence counseling when it comes from peers who are themselves victims of violence. This is the lesson of the Boston-based Violence Prevention Club (VPC), a group of young people who, paralyzed as a result of gunshot wounds, have been successful in carrying the message to other teenagers, according to
Nation's Health.
"When we speak about things we've been through, they really listen," said Naime Padgett, a 19-year-old Bostonian who became a VPC member last year after he suffered a spinal cord injury in a drive-by shooting. "I really feel what we're doing is making a difference."
In Boston the VPC does two kinds of counseling:
- Six of its members counsel new spinal cord injury patients at Boston University Medical Center. The counselors meet patients in the emergency room and visit them regularly in the hospital. "It's really concrete for [spinal cord injury patients] to talk to someone who's been through the same experience," said Robin Barnes, youth coordinator for the hospital's Adolescent Wellness Program. Some patients learn counseling skills and become antiviolence counselors themselves.
- VPC members address groups of teens at schools, community centers, and other locations. They talk about their own life-changing wounds--and how others can protect themselves by avoiding potentially violent situations. "We try to tell them to really think first, to think about the consequences," said Padgett. "We want to teach them how to deal with their anger and that anger is normal."
VPC members' talks have encouraged some teens to improve their behavior, according to follow-up surveys done by public health professionals. The club, which began in Boston, has been replicated in New Jersey and California, and health educators in Chicago may launch the VPC there.
EDUCATION
Teaching Prospects Dim for New PhDs
Doctoral candidates, who have long performed academia's ill-paid donkey work, do so in the 1990s with less hope of being rewarded for it. Nowadays, writes Marc Spiegler in
American Demographics, relatively few of them are likely to become university professors.
The trend is not entirely new. In 1970 more than 68 percent of new PhDs found teaching jobs, but since 1980 only about 51 percent have been similarly fortunate, according to a 1995 study conducted by the National Research Council (NRC). The sharpest drops were shown among new PhDs in the social and behavioral sciences (27 percent) and the life sciences and education (26 percent).
This problem has been exacerbated in recent years as universities, like other public institutions, have been forced to cut their spending. Indeed, some schools have eliminated entire academic departments in an effort to reduce payroll costs. A study by the American Association of University Professors found that faculty hiring in public university systems dropped 30 percent between 1990 and 1995; private schools saw a 12.1 percent drop.
Meanwhile, the pool of potential professors keeps growing. The NRC says that between 1970 and 1993 the number of doctoral degrees awarded in this country jumped from 29,500 to 39,750. Some experts have called on universities to limit the number of doctoral degrees they grant.
However, that would reduce the number of graduate students available to help professors teach undergraduates. "Ostensibly, the purpose of the graduate department is to produce new teachers," says Cary Nelson, an English professor at the University of Illinois at Champaign-Urbana. "In fact, it's a cheap labor pool."
Education is certainly not cheap for the graduate students themselves, many of whom go deeply into debt to pay for an advanced degree of questionable value. Thomas D. Parker, an English professor at Boston University, says, "Many graduate students are like ghetto kids hoping to make the NBA. From a financial standpoint, it's not necessarily a rational decision."