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ACOG Annual Clinical Meeting—General Sessions
continuing education ACOG Annual Clinical Meeting-General Sessions P A M SAROFF, JOGN NURSING S T A F F Proposed changes in obstetric and gynecologic health care were the chief issues explored in general sessions of the Twentieth Annual Clinical Meeting of ACOG, April 1 4 , in Chicago. Midwifery, the future direction of health care delivery and the role and demands of consumers were the key topics probed in Theme Sessions, Great Debates and in a special program. The following excerpts from those programs outline information and ideas presented that are of particular interest and educational benefit to readers as nurses and as consumers.
on the following areas: a) Family arts, b) human development, c ) nutrition (particularly information based on food preferences, economic condition and availability of food), d) education of women for more active participation in health care programs. Include more women in the decision-making processes concerning health care and medical education. Encourage organizations of women health workers to press for changes desired by women. Reevaluate licensing of women health care workers to improve career mobility while maintaining quality of health care. Increase health care for women through industrial health plans. Locate health centers conveniently. Establish community consumer boards. Send more women and minorities to medical schools.
Theme Session I-“What Do Women Want In Health Care?”, Barbara W. Newell, PhD, Pittsburgh, Pennsylvania ( and panelists )
Theme Session 11-Proposed Changes For Health Care Delivery
Recommendations of Participants Work toward integrating a comprehensive health care system. Build on the present system rather than tearing it down and starting anew. Make this system truly responsive and sensitive to the people it serves, including women of very diverse backgrounds, and to the changing sociological roles of women. Treat patients as partners in health care and stop underestimating their intelligence. Explain to women the changes occurring in their bodies rather than assuming the “predominant’’ attitude of “Women just won’t understand.” Women would then become better sources of information for doctors“effective collabrators” in health care. Make a conscious attempt to be sensitive to cultural differences in patients. Refrain from showing personal moral biases to women seeking abortion, suffering venereal disease, etc. Use the health team approach, with fuller utilization of each team member. Reexamine the role of each medical and paramedical member of the team and see that each performs the appropriate functions and that other members assume functions now performed by the doctor where possible, with the aim of providing each patient a total health care package. Encourage pilot projects to develop the team approach to health care, with specific emphasis on those pilots aimed at the elderly woman, the pregnant working woman, the alcoholic woman. Form national advisory groups to aid health workers trying pilot programs. Compile a “how to do” manual on existing health care programs. Develop educational material and disseminate information
“The Governmental Health Care Proposals”, Robert J. Myers, FSA, MAAA, Professor of Actuarial Science, Temple University, Maryland Pressures for health care legislation are largely attributable to three factors. One is wage and price inflation in the United States since 1965. Since that year, physician fees have increased a t a rate almost twice as- high as the cost of living, yet only at about the same rate as wages and salaries. Hospitalization costs have increased a t a much more rapid rate. The second factor is propaganda asserting that American health care is poor. T h e third influence: a fervent aim to change the health care delivery system from diversified to monolithic based on group practice in large institutions. National health proposals on the scene include the following: 1. The American Hospital Association Ameriplan: Requires individuals under age 65 to have private insurance for basic health protection with a government plan for catastrophic costs. Provides complete protection under government plans for the aged and medically indigent. Requires that all medical care be furnished by Health Care Corporations (nonprofit, community-based organizations run essentially by hospitals). The plan is not in legislative form although a bill recently introduced by Congressman Ullman, with AHA support, bears certain similarities to it. That bill does not require that all medical care be furnished by Health Care Corporations although this is strongly encouraged by Federal subsidization of 10% of the insurance cost when such organizations are used. 2. American Medical Association Medicredit (FultonBroyhill Bill) : Allows credits against personal income taxes for the premium costs of qualified private health insurance plans for persons under age 65. Tax credits would be a pro-
portion of the premiums, varying inversely with income. To qualify under Medicredit, a health insurance policy must provide comprehensive protection, including catastrophe coverage, with small cost-sharing by the individual. 3. Health Insurance Association of America, supported by other insurance organizations, Healthcare (Burleson Bill) : Encourages voluntary health insurance under employeremployee plans with voluntary plans for other individuals and State plans for the indigent (with extensive Federal aid). Requires the same minimum benefit structure for all three plans and provides a comprehensive range of benefits to be phased in over the future. Does not provide catastrophe coverage. Offers an incentive t o employers to upgrade their plans to meet the minimum standards. Significantly encourages ambulatory health centers and Health Maintenance Organizations and offers grants for training and health planning. 4. Senator Javits’ Bill: Extends Medicare to persons of all ages. Expands the benefit protection to include physical exams, dental care for youth and out-of-hospital prescription drugs for chronic conditions. Fees would be determined by the government. 5. Senator Kennedy’s Proposal: A plan developed by the Committee for National Health Insurance and supported by the AFL-CIO. Virtually all medical care would be financed through a government system under which about 10% of the cost would be met by employee contributidns, 40% by employers, and the remainder by a government subsidy out of general revenues. Would virtually force physicians into prepaid group practice on an institutional basis since health care institutions (and, therefore, institutional staffs) would be paid in full before private practitioners. 6. Senator Long’s Proposal: Purely catastrophe health insurance financed from payroll taxes and applicable to persons under age 65. Covers, with certain cost-sharing, hospitalization in excess of 60 days per year per person and physician expenses in excess of $2,000 per year per family. A similar proposal was added to Social Security legislation in 1970, but was not enacted. 7. Nixon Proposal: Includes significant encouragement of the Health Maintenance Organization approach and grants to increase health care manpower and general health planning. Requires employers to establish health insurance plans meeting certain specifications and partially financed by employees. A federally operated health insurance plan, with somewhat lower benefit protection, would be provided for low-income families with children and financed predominantly from general revenues with certain cost-sharing payments and certain premiums paid by covered persons above the lowest income levels but not above the maximum income limit.
Action on Proposds Senator Kennedy has held extensive public hearings on his proposal throughout the country. T h e House Ways and Means Committee held hearings last year and planned to consider the matter further in executive session this year. It is extremely unlikely that Congress will act on any of the extensive proposals this election year, but significant legislation in the health care field will likely be enacted this year. Several significant changes in Medicare are contained in a bill passed by the House last year and now being actively considered by the Senate Finance Committee. T h e bill would tighten up ad-
ministration of the existing program and bring it up to date with changes in economic conditions. It would extend Medicare to disabled Social Security beneficiaries under 65 who have been on the benefit rolls for at least two years. Senator Long will possibly add his catastrophe insurance proposal to this pending legislation.
“Obstetric-Gynecologic Health Personnel: The British Midwife,” Colin Campbell, MD, University of Michigan T h e British midwifery system is controlled by a central midwives board. Regulations were imposed on the midwife by the government and not by the midwives themselves. The midwife’s education must include the general equivalent of our high school diploma; at least one year of nurses training and an intensive midwifery course with examinations. Eighteen months of training precede the first exam and six months precede the second. All patients must be seen at some time during pregnancy by a physician who is responsible for assigning or not assigning each patient to a midwife. Law requires the midwife to call in a physician at any sign of abnormality. Statistically, British midwives get better results than US. practitioners, despite the fact that the standard of living in the United Kingdom is definitely lower than in the US.In 1969, the maternal mortality rate in Britain was 19 per 100,000; in the US., 27.4 per 100,OOO; the infant mortality rate for Britain was 12.2 per 1,OOO live births; for the US., 15.4. That year, midwives performed 53% of the deliveries alone and another 18% attended by physicians. Doctors performed only 13% of the total British deliveries. Eighty-four percent of British deliveries were in hospitals and 80% of those were by midwives, mostly without supervision. The neonatal mortality rate for deliveries by midwives was lower than for deliveries by doctors, no doubt due to the fact that doctors delivered the high risk cases.
“Problems For The Obstetrician-Gynecologist In Government-SponsoredHealth Care,” Robert A. € Kinch, I. MD, Montreal, Quebec, Canada Since 1959, Canada has had a national tax-supported hospital insurance plan covering all diagnostic and treatment services in hospital at a standard ward rate. It has removed the specter of financial hardship for prolonged and even for short hospiralization and has been one of the greatest medical advances of the past two decades. It functions extremely well with little overt government control of the doctors’ practice. Since NOvember 1970, all Canadian provinces have been covered by a universal health insurance plan covering all medical services rendered by doctors and related health professionals. This is financed by employees and employers in Quebec. US. doctors may learn from the bad experiences their Canadian counterparts had when opposing aspects of government-sponsored health care. Canadian experience taught the following: T h e first challenge to the American obstetrician in his future approach to total comprehensive medical care insurance is for those representing the profession to cooperate with government in the hope of leading government, rather than hoping to stem the tide by obstinate insistence on the status quo. Physicians should negotiate more as a professional group or medical association than by collective bargaining. It
53
is important that there be unanimity of policy between general practitioners and specialists and that the whole approach to government be backed u p by highly professional, competent and effective public relations and legal advice. It is paramount that organizations of physicians attempting to oppose government legislation avoid the use of the strike weapon. This is harmful to the doctor’s public image as priest-healer (as opposed to the industrialized mechanic of the human body) and to his self-image, which requires that patients’ interests always come first. In order to find the grass roots feelings, we have to talk to them. A continuing dialogue with government is absolutely essential, and by sitting on our thrones we have no influence at all on how health services are provided.
Theme Session 111-Education For The Changing Practice Of Obstetrics and Gynecology ‘The Future of Medicine As Viewed From The Institute of Medicine, National Academy of Sciences,” John R. Hogness, MD, Washington, D.C. Predicted general changes during the next thirty years include the following:
In the organization of the delivery system: larger management units; all persons in one unit will share indirectly in management and directly in financial success; solo practice will disappear; more meaningful teams for health care with the roles of participants much more clearly defined; much more involvement of management and business oriented people in the system. In the financing of care: some form of universal guaranteed payment with compulsory participation will be gradually implemented; methods of financing the health care system will be scrutinized to see how they effect the cost of health care; experiments with various incentives, including the profit motive; financing will not come primarily from general tax revenues; gradual disappearance of fee for service as we know it as total health centers emerge. In production and distribution of manpower: a break away from traditional curriculum; more flexibility in the curriculum and in the time necessary to earn the MD degree; greater coordination between undergraduate and postgraduate programs; experiments in educating the health care delivery team members together; greater orientation toward community needs. In Information System: Standardization of records in the physicians’ offices, hospitals and in insurance forms; physicians and nurses will eventually deal directly with a computer to record and review information; the future storage systems will make information easily transferable from hospital to hospital, city to city.
Great Debate 2--“Resolved: The Physicians’ Nurse Associate May Provide Complete Maternity Care” A f i m a t i v e views from John V a n S. Maeck, M D , Burlington, Vermont, and George R. Huggins, M D , Jackson, Mississippi The obstetrician-nurse midwife team is preferable to solo practice by either member. Each brings his own special ex-
54
pertise to the practice and the combined expertise is greater than the sum of its parts. The team approach would ideally free the OB to devote his expertise to the patient at risk. The nurse midwife should and can provide certain aspects of care to all patients, not solo care to any patient. A number of midwifery systems, such as Kentucky Frontier Nursing Service, have proved nurse midwives can provide safe, high quality care. Nurse midwives are particularly needed in communities with low socioeconomic levels. When used in such communities in the US., they have improved infant and neonatal mortality rates. In numerous instances, delivery room nurses must do deliveries, but without special training. Sometimes they cannot even legally do vaginal exams to examine the course of labor.
Negative views f r o m Damell L. Brawner, M D , Savannah, Georgia, and Bruce D. Stern, M D , Beverly Hills, California There is no need for the nurse associate because the birth rate is decreasing and the number of doctors is increasing. W e are now at zero population increase and there are less women of childbearing age than ever before. With current medical school expansion, in the next few years the alleged shortage of physicians will be over. By 1975, enrollments in medical schools will have doubled.
In New York, biggest advocate of midwifery, from 1960 to 1970 the birth rate dropped 17%. A sampling of private OB patients polled said they are not willing to sacrifice a physician’s expertise for “more” care offered by the midwife. They fear complications, and would accept a midwife only as “second best” if they were poor. The most negative results of delegating the “heart of our specialty” to nurse midwives would be the loss of the patientdoctor relationship. There are too few nurses to go around now. The poor prefer doctors. Blacks in Watts say their people do not want nurse midwives. They want the same quality care as middle class whites receive. A better answer to the shortage of doctors in minority group communities is to get more minority members in medical schools. Malpractice insurance coverage for nurse midwives would increase overhead costs for doctors.
Special Program-“An Obstetrician-Gynecologist Looks At Capitol Hill,” Congressman William R. Roy, MD, Washington, D.C. The Federal government role in medical care will stop in-
creasing only when quality medical care is available to all our citizens. Some type of universal payment mechanism is inevitable during this decade. T h e public wants relief from rising medical expenses which now exceed $400 per year for a family of four, and because each year a catastrophic illness strikes one million American families. W e are likely to see an increase in Medicare coverage financed by additional payroll taxes and further diversion of Social Security dollars to Medicare. W e can expect government requirement of quality assurance. Assessment by peer review seems to be the most promising technique to assess quality and intervene when poor quality medical care is evident. Congressmen want to design and pass modest legislation which will benefit all parties involved. There is no evidence that any legislative committee is now working with organized medicine. “I regret that we do not have cooperation of organized medicine because I believe we should take the same attitude toward all patients collectively as toward individual private patients.” If physicians continue to fight every bill that comes down the pike, it will result in escalating legislation to the detriment of the profession and the people. Physicians should therefore talk carefully with their legislators-those who will write legislation-especially the House Ways and Means and Senate Finance committees and members of the majority party on health-related committees.
Opportunites in Education C%&es for Obstetrics and Gynecology and Administrator Nurses will be featured a t the lSth Annual Postgraduate Refresher course for Physicians in Honolulu and Maui, August 12-23, presented by the University of Southern California and University of Hawaii Schools of Medicine and the Institute of Continuing Education for the Nurse Practitioner. Subjects under study will include: the abnormal pap smear, contraception, evaluation of labor, fetal heart rate patterns and diagnosis, treatment of fetal distress, intrapartium fetal mechanics of monitoring, venereal disease, and administration-the common process and effective utilization of resourses and decision making. Tuition is $100 for OB nurses; $110 for nurse administrators. No courses will be scheduled afternoons or weekends. A basic tour transportation package is available-details available from the Associate Dean, Postgraduate Division, USC School of Medicine, 2025 Zonal Avenue, Los Angeles, California 90033. A Graduate Workshop in Childbirth Education will be conducted in Los Angeles County, July 10-21, by T h e American Institute of Family Relations in collaboration with Pepperdine University, primarily for teachers of expectant parents; the course is also open to graduate OB nurses and Health and Family Life educators. Among lesson topics: organizing and publicizing a childbirth education program, sponsorship and fee, program adaptation to needs of different groups, beginning the first meeting, forms and records, audiovisual aids and duplicated material. Registration fee is $100; graduate credits can be earned. Further information is available from Mary Jane Hungerford, PhD, Workshop Division, 5287 Sunset Blvd., Los Angeles, California, 90027. The 16th International Congress of Midwives, sponsored by International Confederation of Midwives will be held October 28-November 3 at the Sheraton-Park Hotel, in Washington, D.C.Scientific and clinical presentation are planned on obstetric management, prevention of birth defects, family planning,
parent and midwifing education, with simultaneous translation in several languages. Address inquiries to Miss Laverne Werner, ICM-US, Planning Committee, 346 E. 29th Street, No. 2-D, Brooklyn, New York 11226. T h e Symposium on Fetal Monitoring at Deaconess Hospital, Buffalo, New York, June 23, 24, will cover new approaches to the high-risk pregnancies with special emphasis on biophysical methods of fetal mqnotoring in labor and delivery rooms. For further information contact Norman Courey, MD, Department of Gynecology/Obstetrics, Deaconess Hospital, 1001 Humboldt Parkway, Buffalo, New York 14208. Intensive training for Family Planning nurse specialists will be offered in January, May and September of 1973, according to Planned Parenthood, World Population Cosponsors. The 12week program combines classroom and clinical teaching and experience for different clinical specialists and trained nurses in Family Planning Service Organization and Administration, Interviewing, Communication and Teaching. Each class is limited to 10 trainees, and preference is given to nurses from agencies or hospitals which provide or expect t o provide Family Planning Service. Accepted applicants will receive full tuition. Sessions will be held at the Martland General Hospital Unit of the New Jersey College of Medicine and Dentistry and the Planned Parenthood Center Clinic, Assex County cosponsors. Address application to Mrs. Miriam Manisoff, Planned Parenrhood, 810 7th Avenue, New York, N. Y. 10019. T h e University of Michigan School of Public Health has arranged a Maternal and Childhealth Program of Study leading to a Master in Public Health. Open to nurses, courses include general maternal and child health, community pediatrics, community obstetrics and gynecology, mental retardation and related disabilities. Fellowships are available to applicants who are U.S. citizens. Address inquiries ro Donald C. Smith, MD, University of Michigan, 1420 Washington Heights, Ann Arbor, Michigan, 48104.
on the following areas: a) Family arts, b) human development, c ) nutrition (particularly information based on food preferences, economic condition and availability of food), d) education of women for more active participation in health care programs. Include more women in the decision-making processes concerning health care and medical education. Encourage organizations of women health workers to press for changes desired by women. Reevaluate licensing of women health care workers to improve career mobility while maintaining quality of health care. Increase health care for women through industrial health plans. Locate health centers conveniently. Establish community consumer boards. Send more women and minorities to medical schools.
Theme Session I-“What Do Women Want In Health Care?”, Barbara W. Newell, PhD, Pittsburgh, Pennsylvania ( and panelists )
Theme Session 11-Proposed Changes For Health Care Delivery
Recommendations of Participants Work toward integrating a comprehensive health care system. Build on the present system rather than tearing it down and starting anew. Make this system truly responsive and sensitive to the people it serves, including women of very diverse backgrounds, and to the changing sociological roles of women. Treat patients as partners in health care and stop underestimating their intelligence. Explain to women the changes occurring in their bodies rather than assuming the “predominant’’ attitude of “Women just won’t understand.” Women would then become better sources of information for doctors“effective collabrators” in health care. Make a conscious attempt to be sensitive to cultural differences in patients. Refrain from showing personal moral biases to women seeking abortion, suffering venereal disease, etc. Use the health team approach, with fuller utilization of each team member. Reexamine the role of each medical and paramedical member of the team and see that each performs the appropriate functions and that other members assume functions now performed by the doctor where possible, with the aim of providing each patient a total health care package. Encourage pilot projects to develop the team approach to health care, with specific emphasis on those pilots aimed at the elderly woman, the pregnant working woman, the alcoholic woman. Form national advisory groups to aid health workers trying pilot programs. Compile a “how to do” manual on existing health care programs. Develop educational material and disseminate information
“The Governmental Health Care Proposals”, Robert J. Myers, FSA, MAAA, Professor of Actuarial Science, Temple University, Maryland Pressures for health care legislation are largely attributable to three factors. One is wage and price inflation in the United States since 1965. Since that year, physician fees have increased a t a rate almost twice as- high as the cost of living, yet only at about the same rate as wages and salaries. Hospitalization costs have increased a t a much more rapid rate. The second factor is propaganda asserting that American health care is poor. T h e third influence: a fervent aim to change the health care delivery system from diversified to monolithic based on group practice in large institutions. National health proposals on the scene include the following: 1. The American Hospital Association Ameriplan: Requires individuals under age 65 to have private insurance for basic health protection with a government plan for catastrophic costs. Provides complete protection under government plans for the aged and medically indigent. Requires that all medical care be furnished by Health Care Corporations (nonprofit, community-based organizations run essentially by hospitals). The plan is not in legislative form although a bill recently introduced by Congressman Ullman, with AHA support, bears certain similarities to it. That bill does not require that all medical care be furnished by Health Care Corporations although this is strongly encouraged by Federal subsidization of 10% of the insurance cost when such organizations are used. 2. American Medical Association Medicredit (FultonBroyhill Bill) : Allows credits against personal income taxes for the premium costs of qualified private health insurance plans for persons under age 65. Tax credits would be a pro-
portion of the premiums, varying inversely with income. To qualify under Medicredit, a health insurance policy must provide comprehensive protection, including catastrophe coverage, with small cost-sharing by the individual. 3. Health Insurance Association of America, supported by other insurance organizations, Healthcare (Burleson Bill) : Encourages voluntary health insurance under employeremployee plans with voluntary plans for other individuals and State plans for the indigent (with extensive Federal aid). Requires the same minimum benefit structure for all three plans and provides a comprehensive range of benefits to be phased in over the future. Does not provide catastrophe coverage. Offers an incentive t o employers to upgrade their plans to meet the minimum standards. Significantly encourages ambulatory health centers and Health Maintenance Organizations and offers grants for training and health planning. 4. Senator Javits’ Bill: Extends Medicare to persons of all ages. Expands the benefit protection to include physical exams, dental care for youth and out-of-hospital prescription drugs for chronic conditions. Fees would be determined by the government. 5. Senator Kennedy’s Proposal: A plan developed by the Committee for National Health Insurance and supported by the AFL-CIO. Virtually all medical care would be financed through a government system under which about 10% of the cost would be met by employee contributidns, 40% by employers, and the remainder by a government subsidy out of general revenues. Would virtually force physicians into prepaid group practice on an institutional basis since health care institutions (and, therefore, institutional staffs) would be paid in full before private practitioners. 6. Senator Long’s Proposal: Purely catastrophe health insurance financed from payroll taxes and applicable to persons under age 65. Covers, with certain cost-sharing, hospitalization in excess of 60 days per year per person and physician expenses in excess of $2,000 per year per family. A similar proposal was added to Social Security legislation in 1970, but was not enacted. 7. Nixon Proposal: Includes significant encouragement of the Health Maintenance Organization approach and grants to increase health care manpower and general health planning. Requires employers to establish health insurance plans meeting certain specifications and partially financed by employees. A federally operated health insurance plan, with somewhat lower benefit protection, would be provided for low-income families with children and financed predominantly from general revenues with certain cost-sharing payments and certain premiums paid by covered persons above the lowest income levels but not above the maximum income limit.
Action on Proposds Senator Kennedy has held extensive public hearings on his proposal throughout the country. T h e House Ways and Means Committee held hearings last year and planned to consider the matter further in executive session this year. It is extremely unlikely that Congress will act on any of the extensive proposals this election year, but significant legislation in the health care field will likely be enacted this year. Several significant changes in Medicare are contained in a bill passed by the House last year and now being actively considered by the Senate Finance Committee. T h e bill would tighten up ad-
ministration of the existing program and bring it up to date with changes in economic conditions. It would extend Medicare to disabled Social Security beneficiaries under 65 who have been on the benefit rolls for at least two years. Senator Long will possibly add his catastrophe insurance proposal to this pending legislation.
“Obstetric-Gynecologic Health Personnel: The British Midwife,” Colin Campbell, MD, University of Michigan T h e British midwifery system is controlled by a central midwives board. Regulations were imposed on the midwife by the government and not by the midwives themselves. The midwife’s education must include the general equivalent of our high school diploma; at least one year of nurses training and an intensive midwifery course with examinations. Eighteen months of training precede the first exam and six months precede the second. All patients must be seen at some time during pregnancy by a physician who is responsible for assigning or not assigning each patient to a midwife. Law requires the midwife to call in a physician at any sign of abnormality. Statistically, British midwives get better results than US. practitioners, despite the fact that the standard of living in the United Kingdom is definitely lower than in the US.In 1969, the maternal mortality rate in Britain was 19 per 100,000; in the US., 27.4 per 100,OOO; the infant mortality rate for Britain was 12.2 per 1,OOO live births; for the US., 15.4. That year, midwives performed 53% of the deliveries alone and another 18% attended by physicians. Doctors performed only 13% of the total British deliveries. Eighty-four percent of British deliveries were in hospitals and 80% of those were by midwives, mostly without supervision. The neonatal mortality rate for deliveries by midwives was lower than for deliveries by doctors, no doubt due to the fact that doctors delivered the high risk cases.
“Problems For The Obstetrician-Gynecologist In Government-SponsoredHealth Care,” Robert A. € Kinch, I. MD, Montreal, Quebec, Canada Since 1959, Canada has had a national tax-supported hospital insurance plan covering all diagnostic and treatment services in hospital at a standard ward rate. It has removed the specter of financial hardship for prolonged and even for short hospiralization and has been one of the greatest medical advances of the past two decades. It functions extremely well with little overt government control of the doctors’ practice. Since NOvember 1970, all Canadian provinces have been covered by a universal health insurance plan covering all medical services rendered by doctors and related health professionals. This is financed by employees and employers in Quebec. US. doctors may learn from the bad experiences their Canadian counterparts had when opposing aspects of government-sponsored health care. Canadian experience taught the following: T h e first challenge to the American obstetrician in his future approach to total comprehensive medical care insurance is for those representing the profession to cooperate with government in the hope of leading government, rather than hoping to stem the tide by obstinate insistence on the status quo. Physicians should negotiate more as a professional group or medical association than by collective bargaining. It
53
is important that there be unanimity of policy between general practitioners and specialists and that the whole approach to government be backed u p by highly professional, competent and effective public relations and legal advice. It is paramount that organizations of physicians attempting to oppose government legislation avoid the use of the strike weapon. This is harmful to the doctor’s public image as priest-healer (as opposed to the industrialized mechanic of the human body) and to his self-image, which requires that patients’ interests always come first. In order to find the grass roots feelings, we have to talk to them. A continuing dialogue with government is absolutely essential, and by sitting on our thrones we have no influence at all on how health services are provided.
Theme Session 111-Education For The Changing Practice Of Obstetrics and Gynecology ‘The Future of Medicine As Viewed From The Institute of Medicine, National Academy of Sciences,” John R. Hogness, MD, Washington, D.C. Predicted general changes during the next thirty years include the following:
In the organization of the delivery system: larger management units; all persons in one unit will share indirectly in management and directly in financial success; solo practice will disappear; more meaningful teams for health care with the roles of participants much more clearly defined; much more involvement of management and business oriented people in the system. In the financing of care: some form of universal guaranteed payment with compulsory participation will be gradually implemented; methods of financing the health care system will be scrutinized to see how they effect the cost of health care; experiments with various incentives, including the profit motive; financing will not come primarily from general tax revenues; gradual disappearance of fee for service as we know it as total health centers emerge. In production and distribution of manpower: a break away from traditional curriculum; more flexibility in the curriculum and in the time necessary to earn the MD degree; greater coordination between undergraduate and postgraduate programs; experiments in educating the health care delivery team members together; greater orientation toward community needs. In Information System: Standardization of records in the physicians’ offices, hospitals and in insurance forms; physicians and nurses will eventually deal directly with a computer to record and review information; the future storage systems will make information easily transferable from hospital to hospital, city to city.
Great Debate 2--“Resolved: The Physicians’ Nurse Associate May Provide Complete Maternity Care” A f i m a t i v e views from John V a n S. Maeck, M D , Burlington, Vermont, and George R. Huggins, M D , Jackson, Mississippi The obstetrician-nurse midwife team is preferable to solo practice by either member. Each brings his own special ex-
54
pertise to the practice and the combined expertise is greater than the sum of its parts. The team approach would ideally free the OB to devote his expertise to the patient at risk. The nurse midwife should and can provide certain aspects of care to all patients, not solo care to any patient. A number of midwifery systems, such as Kentucky Frontier Nursing Service, have proved nurse midwives can provide safe, high quality care. Nurse midwives are particularly needed in communities with low socioeconomic levels. When used in such communities in the US., they have improved infant and neonatal mortality rates. In numerous instances, delivery room nurses must do deliveries, but without special training. Sometimes they cannot even legally do vaginal exams to examine the course of labor.
Negative views f r o m Damell L. Brawner, M D , Savannah, Georgia, and Bruce D. Stern, M D , Beverly Hills, California There is no need for the nurse associate because the birth rate is decreasing and the number of doctors is increasing. W e are now at zero population increase and there are less women of childbearing age than ever before. With current medical school expansion, in the next few years the alleged shortage of physicians will be over. By 1975, enrollments in medical schools will have doubled.
In New York, biggest advocate of midwifery, from 1960 to 1970 the birth rate dropped 17%. A sampling of private OB patients polled said they are not willing to sacrifice a physician’s expertise for “more” care offered by the midwife. They fear complications, and would accept a midwife only as “second best” if they were poor. The most negative results of delegating the “heart of our specialty” to nurse midwives would be the loss of the patientdoctor relationship. There are too few nurses to go around now. The poor prefer doctors. Blacks in Watts say their people do not want nurse midwives. They want the same quality care as middle class whites receive. A better answer to the shortage of doctors in minority group communities is to get more minority members in medical schools. Malpractice insurance coverage for nurse midwives would increase overhead costs for doctors.
Special Program-“An Obstetrician-Gynecologist Looks At Capitol Hill,” Congressman William R. Roy, MD, Washington, D.C. The Federal government role in medical care will stop in-
creasing only when quality medical care is available to all our citizens. Some type of universal payment mechanism is inevitable during this decade. T h e public wants relief from rising medical expenses which now exceed $400 per year for a family of four, and because each year a catastrophic illness strikes one million American families. W e are likely to see an increase in Medicare coverage financed by additional payroll taxes and further diversion of Social Security dollars to Medicare. W e can expect government requirement of quality assurance. Assessment by peer review seems to be the most promising technique to assess quality and intervene when poor quality medical care is evident. Congressmen want to design and pass modest legislation which will benefit all parties involved. There is no evidence that any legislative committee is now working with organized medicine. “I regret that we do not have cooperation of organized medicine because I believe we should take the same attitude toward all patients collectively as toward individual private patients.” If physicians continue to fight every bill that comes down the pike, it will result in escalating legislation to the detriment of the profession and the people. Physicians should therefore talk carefully with their legislators-those who will write legislation-especially the House Ways and Means and Senate Finance committees and members of the majority party on health-related committees.
Opportunites in Education C%&es for Obstetrics and Gynecology and Administrator Nurses will be featured a t the lSth Annual Postgraduate Refresher course for Physicians in Honolulu and Maui, August 12-23, presented by the University of Southern California and University of Hawaii Schools of Medicine and the Institute of Continuing Education for the Nurse Practitioner. Subjects under study will include: the abnormal pap smear, contraception, evaluation of labor, fetal heart rate patterns and diagnosis, treatment of fetal distress, intrapartium fetal mechanics of monitoring, venereal disease, and administration-the common process and effective utilization of resourses and decision making. Tuition is $100 for OB nurses; $110 for nurse administrators. No courses will be scheduled afternoons or weekends. A basic tour transportation package is available-details available from the Associate Dean, Postgraduate Division, USC School of Medicine, 2025 Zonal Avenue, Los Angeles, California 90033. A Graduate Workshop in Childbirth Education will be conducted in Los Angeles County, July 10-21, by T h e American Institute of Family Relations in collaboration with Pepperdine University, primarily for teachers of expectant parents; the course is also open to graduate OB nurses and Health and Family Life educators. Among lesson topics: organizing and publicizing a childbirth education program, sponsorship and fee, program adaptation to needs of different groups, beginning the first meeting, forms and records, audiovisual aids and duplicated material. Registration fee is $100; graduate credits can be earned. Further information is available from Mary Jane Hungerford, PhD, Workshop Division, 5287 Sunset Blvd., Los Angeles, California, 90027. The 16th International Congress of Midwives, sponsored by International Confederation of Midwives will be held October 28-November 3 at the Sheraton-Park Hotel, in Washington, D.C.Scientific and clinical presentation are planned on obstetric management, prevention of birth defects, family planning,
parent and midwifing education, with simultaneous translation in several languages. Address inquiries to Miss Laverne Werner, ICM-US, Planning Committee, 346 E. 29th Street, No. 2-D, Brooklyn, New York 11226. T h e Symposium on Fetal Monitoring at Deaconess Hospital, Buffalo, New York, June 23, 24, will cover new approaches to the high-risk pregnancies with special emphasis on biophysical methods of fetal mqnotoring in labor and delivery rooms. For further information contact Norman Courey, MD, Department of Gynecology/Obstetrics, Deaconess Hospital, 1001 Humboldt Parkway, Buffalo, New York 14208. Intensive training for Family Planning nurse specialists will be offered in January, May and September of 1973, according to Planned Parenthood, World Population Cosponsors. The 12week program combines classroom and clinical teaching and experience for different clinical specialists and trained nurses in Family Planning Service Organization and Administration, Interviewing, Communication and Teaching. Each class is limited to 10 trainees, and preference is given to nurses from agencies or hospitals which provide or expect t o provide Family Planning Service. Accepted applicants will receive full tuition. Sessions will be held at the Martland General Hospital Unit of the New Jersey College of Medicine and Dentistry and the Planned Parenthood Center Clinic, Assex County cosponsors. Address application to Mrs. Miriam Manisoff, Planned Parenrhood, 810 7th Avenue, New York, N. Y. 10019. T h e University of Michigan School of Public Health has arranged a Maternal and Childhealth Program of Study leading to a Master in Public Health. Open to nurses, courses include general maternal and child health, community pediatrics, community obstetrics and gynecology, mental retardation and related disabilities. Fellowships are available to applicants who are U.S. citizens. Address inquiries ro Donald C. Smith, MD, University of Michigan, 1420 Washington Heights, Ann Arbor, Michigan, 48104.