Sociology exam 2

Trend in nurse roles

-Evolution of RN into administrative role -to reach top of medical hierarchy, nurse forced to leave nursing altogether (but usually impractical) -instead seek career in hospital administration -used more economically in managerial and supervisory positions b/c lower paid do bedside tasks -allows nurse to secure claim of professional status, but it reduced contact with patients for which nursing was organized in first place -removing best qualified nurses from bedside

Benefits of health management organizations

-HMO = form of prepaid group practice emphasizing preventive care -response of govt. to demands for federal intervention to rising cost of healthcare to support improvements in health care delivery for all segments of the population, exert limited control over physicians, and initiate efforts to reform health care delivery system -Half of funds for HMS allocated to areas that were medically undeserved -Although doctors and hospitals still controlled the efforts of professional standard review organizations, the sum total of regulatory efforts went beyond what physicians and hospitals wanted -planning not aimed at expansion but containment -formally linked for the first time with regulation -managed care refers to health care organizations that manage or control the cost of health care by monitoring how doctors treat specific illnesses, limit referrals to specialists, and require authorization prior to hospitalization, etc. -doctors have to work in accordance with regulations and fee structure set by the plan that employs them -organize and improve health care in a stable, reliable, and less costly manner -combine prevention with patient education -disadvantages: disrupt doctor-patient relationships, take deep discounts out of doctor and hospital fees, and produce large profits without w/o developing good managed clinical care

Pros and cons of socialized healthcare

-System of healthcare delivery in which health care is provided in the form of a state-supported consumer service -health care is purchased, but the buyer is the govt., which makes services available at little or no additional cost to the consumer -diff. forms in Britain, Canada, and Sweden -govt. directly controls financing and organization of health services in capitalist economy -govt. directly pays providers -govt. owns most of facilitirs -guarantees equal access to general population -allows some private care for patients willing to be responsible for own expenses

Importance of professionalization for nurses

-growth of associate degree programs has presented special problem in terms of nursing's claims of professional status -AD programs are vocational, not professional -thus, strategy was to assign these nurses as 'technical' nurses and baccalaureate nurses as 'professional nurses' while emphasizing that all nurses be graduates of college programs at some time in the future -initially, baccalaureate nurses regarded as most professional yet associate and diplomas nurses also considered themselves to be professionals -hospitals began requiring nurses to have bachelor's degrees to be hired or keep their jobs, sending many AD nurses back to school for RN to BSN programs (registered nurse to bachelor of science nurse)

What does CAM entail

-use of treatments that are not commonly practiced by the medical profession -includes chiropractors, faith healers, folk healers, acupunctures, homeopaths, naturopaths, dietary supplements to prevent or cure disease, aromatherapy, shiatsu (Japanese massage), ayurveda (oils and massage in India to treat insomnia and hypertension), crystal healing (healing energy from minerals), biofeedback (machines to train people to control involuntary bodily functions)

Feature of professionalism

1. prolonged training in a body of specialized and abstract knowledge 2. orientation toward providing a service once a professional group becomes established, if consolidates power by formalizing social relationships that govern interaction of the professionals with clients, colleagues, and official agencies outside the profession once public accepts claims to competence and control of its membership, additional features established: -profession determines its own standards of education and training -student professional goes through a more stringent socialization experience than the learner in other occupations -professional practice is often legally recognized by some form of license -licensing and admission boards staffed by members of the profession -most legislation concerned w/ the profession is shaped by that profession -as occupation gains income, power, and prestige it can demand high caliber students -practitioner is relatively free of lay evaluation and control -members are strongly identified by profession

Difference between a DO and MD

DO= doctor of osteopathy; centered around a more holistic view of medicine in which the focus is on seeing the patient as a "whole person" to reach a diagnosis, rather than treating the symptoms alone. (chiropractor) MD= allopathic medicine; classical form of medicine, focused on the diagnosis and treatment of human diseases ~800,000 physicians in the US; roughly 50,000 are DO's, remaining 750,000 MDs. -DO programs tend to produce physicians who go on to practice in primary care

Infant mortality rate between countries

Japan and Finland have lowest infant mortality rate in world, Norway next US 25th among 30 countries Poland, Hungary, Ne Zealand, and Slovak Republic all had lower rates of infant mortality than the US

How do hospitals strip power

Patients alienated from usual lives and reduced to a largely impersonal status in hospital through: 1. stripping 2. control of resources 3. restriction of mobility -Stripping: hospital systematically divests the person of past presentations of self (attitudes, beliefs, values, concept of self, and social status) by taking away clothes and given uniform, visiting regulation, staff supervises diet, decides when patient can sleep or be awake, and controls general conduct of patient's social life in the hospital -seriousness of illness not indicative if patient would conform to hospital routine, rather age and education were best predictors (the younger and more educated, the less likely they were to express conforming attitudes while older and less educated more likely to conform)

Healthcare systems (general) of Canada, Britain, Sweden, Japan, Germany, Mexico, China, Russia

Socialized medicine: Canada, Britain, Sweden Decentralized National Health Programs: Japan, Germany, and Mexico Socialist medicine: Russia and China Canada: -private system paid for almost entirely by public money -doctor fees paid for by govt. sponsored national health insurance (Medicare) according to fees negotiated by territorial govt. -hospitals operate on budget negotiated with govt. officials -not single health care delivery but 10 provincial and 3 territory ones -not decentralized b/c fed govt. influences health policy and delivery of care through budget -universal health care has reduced social disparities but not eliminated them -universal coverage w/ cost controls since govt. buys all care and can control cots of that care -also have private hospitals/insurance -infant mortality lower than US Britain -established first health care system to offer free medical care to the entire population -NHS goal: provide free, comprehensive medical care (accomplished this) -general practitioner is first line of medical care, paid for each patient on their list (more patients they see, more money they make) -paying less for more was difficult as population grow -specialists make more =resentment -long waits -can have private patients who pay own bills -significant inequalities remain between social classes (living environments associated with poverty rather than access to quality health care) -infant mortality lower than US Sweden: -effective in low infant mortality and high life expectancy -have more homogeneous population with fewer social class differences -taxation highest in world but welfare benefits generous -inequities in living conditions more equal than most countries -one of healthiest populations overall -physicians employed by councils and paid by numbers of hours worked, not number of patients -hospitals owned by govt. -most revenues come from county councils (71%) Japan: -effective in low infant mortality and high life expectancy -have homogeneous population with fewer social class differences -low cost and readily accessibly but economic conditions primary factor as large business corporation have expense of providing health benefits to employees cost free -people under 70 are responsible for up to 30% of cost of care monthly -use of prescription drugs highest in world -NHP does not cover all Japanese, rather govt. encouraged private organizations to keep govt. involvement at minimum by setting up own welfare benefits (business world responsible for taking care of employees) -Japanese govt. limits how much hospitals can charge, so hospitals often required to admit more patients to meet expenses = overcrowding -old age population increasing in Japanese society faster than in any other country - need response from Japan's health care delivery Germany -first country to enact national health insurance -compulsory insurance -free health services -sick benefits -90% participate, remained have own insurance -govt. primary role in administration, not in financing health services -payment made to physician through doctor's association according to fee agreed upon by association and public health insurance plans -higher amount of general practitioners -has lowest birthrate and aging population which signals higher expenses in future = less tax revenues to support health care Mexico -decentralized national health system, covers 98% of population through: 1. public social security organizations: health insurance and old age benefits 2. health care from govt. welfare SSA 3. private health care system -serious maldistribution of services, with most in cities and shortage in rural areas -oriented toward curative and not preventive medicine China: -financed largely by patients, employers, and health insurance copmanies, no longer socialist system in which state control organizes and finances health care directly to all citizens free of charge -one of first public health measures was to improve sanitation, revive traditional medicine, and barefoot doctors of paramedics who assisted in preventive medicine and public health giving basic health care central govt. covers less than 1% of health expenditures -health services delegated to provincial and county govt. but only covers min. wages for health care workers and capital investment for new facilities, rest covered by patient fees -hospitals generate own incomes, leading to fee-for service model -well educated and higher income Chinese tend to have worse health in these cohorts than less educated and low income persons (unhealthy life choices) Russia: -compulsory and voluntary plans -compulsory health insurance plan financed by central govt. subsidies for pensioners and unemployed along with contributions from employers -health insurance mandatory for all employees -same basic benefits w/o choice -administrated by regional govt. health insurance funds that make payments to private insurance companies -move away from Soviet method of govt. paying for all health care and replace with universal system of health insurance that provides basic benefits in form of payments to providers -shifted funding from federal to local level so financing of health care comes locally -decline of life expectancy was unseen in anywhere else in world (alcohol use, cigarette consumption)

Free-standing emergency centers

take businesses away from hospitals (7/11 Medicine, Docs-in-a-Box) that are not affiliated with a hospital but open 24/7

How can religion and prayer seemingly help people's health issues

-appeal to a spiritual or divine being promotes sense of psychological well being in an individual -among elderly persons, those with highest levels of religious involvement showed the least depression and physical disability -religiousness is important for many people in poor health as sick people use their religion to help them cope with their illness -prayer could be form of CAM as ranks as top of activities in which people engage in with respect to health compared to other CAM practices -religion associated with pos. levels of health and lower mortality -religion tends to promote good health by encouraging pos. health lifestyle practices and discouraging harmful habits -high religious participation has lower levels of risk behaviors like smoking, alcohol, and drug use, risky sex, lack of physical activity, high-fat diet, etc. -faith healers: people who use power of prayer and faith to promote healing -healing through psychological processes and effective only with psychophysiological disorders or intervention of God and constitutes a miracle -not essentially cure but alleviation of symptoms usually reported (relief from psychological distress, acceptance of one's life situation, or new perspective, redefined ailment as less serious) -relief from stress, enhanced feelings of support from God, and adoption of a different viewpoint about the meaning of their health problem in their lives

Phases of nursing students

1. Initial innocence: nursing students wanting to do things out of kindness/care, education aimed to emphasize looking at patient objectively 2. labeled recognition of incongruity: question decision to become nurse, couldn't adjust to incongruity b/w expectations and actual training 3. psyching out: students attempt to anticipate what instruction wants 4. role simulation: exhibit objective and 'professional' or detached attitude toward patient care; acting like a nurse 5. provisional internalization: took on temporary self identity as a 'professional nurse' as defined by the faculty 6. stable internalization: settled into identification as professional nurse

changing physician-patient relationships

1. shift in medicine away from treatment of acute disease toward preventive health services intended to offset the effects of chronic disorders 2. growing sophistication of the general public with bureaucracy and the development of consumerism

Florence Nightingale

1850s, English protestant -established hospital for sick distressed women and staffed it with trained nurses from good families -wanted to make nursing an honorable and respected occupation through formal training and recruiting from upper and middle class social backgrounds -eventually, her nurses were requested and became known as angels of mercy -emphasized code of behavior that idealized nurses as being responsible, clean, self-sacrificing, courageous, cool headed, hardworking, obedient to physician, and possessing qualities of a mother -perpetuated idea of social role of nurse as a female supervised and controlled by a male physician (at time, way to gain access to official position in male-dominated field of medicine) -ideas formed basis for establishing first accredited nursing schools in US - funded by hospitals that provided financial support in turn thta student furnish nursing services -respectable occupation for women

Largest single group of health workers in US

nurses 3 million employed as RN 725,000 employed as licensed practical nurses that same year

Chiropractors

-Gradually achieved professional respectability by moving away from an exclusive focus on spinal manipulation to treat general health -now part of mainstream medicine as physicians w/ added skill of training in spinal procedures -mid 1950s were receiving scientific medical training in surgery and pharmacology -training takes place at 19 osteopathic colleges in US whose graduates are awarded the DO (Doctor of Osteopathy). Further training as an intern and resident is required. -Have own organization AOA which promotes professionalism -AMA recognizes osteopaths as medical speciality in 1950s and now they enjoy rights and privileges of medical doctors -Have maintained own identity but trending toward absorption in medicine although resisting complete assimilation into traditional medicine -Can specialize in variety of medical specialities Some believe therapeutic practices originally designed to distinguish osteopathy from traditional medicine have become less and less important to majority of its practitioners -licensed to practice in all states and authorized to receive medicare payments and private insurance carriers -attempts at professionalization hampered by physicians and inner conflicts - some want to expanded role with variety of techniques while others favor pure approach to just spinal manipulation; compete with each other for patients -physicians rarely refer patients to chiropractors, so most visit chiropractors on own initiative -second largest category of primary health care practitioners in US, just after MDs, when number of providers and patients treated is taken into account, yet they remain outside mainstream medicine

Major factors in decline in status of physicians

-deprofessionalization: decline in a profession's autonomy and control over clients -in physicians, this authority is no longer absolute and medical work subject to scrutiny by patients, health care organizations, and govt. -pressure on physicians from below (consumers) and above (govt. and business corporations) -1950s, medical profession in US stood at height of professional power w/ great public trust - unprecedented level of professional control "Golden Age" and "Age of Gold" for physicians - led to loss of public trust b/c profits soared -public dissatisfaction w/ medical profession had economic and social origins -decline in early 2000s of professionalism; professional dominance no longer adequate theory -countervailing power: medical profession was but one of many powerful groups in society (state, employers paying for insurance for employees, patients as consumers, etc) maneuvered to fulfill interests in healthcare - ended monopoly as lost control of market -oversupply of doctors and fragmentation and lack of success in resisting govt. controls of its labor union the AMA weakened the medical profession internally -state shifted allegiance from professional interests to private interests, especially those intended to better health of the general public and contain costs -AMA was a dominant institutional force in govt. but now that is no longer the case as organized medicine has lost power to determine health policy -increased consumerism on part of patients and greater government and corporate control over medical practice have resulted in the decline of the professional status -doctors moving away from being the absolute authority in medical matters toward having lessened authority w/ patients insisting on greater equality in relationship and corporate health organization that employ doctors seeking to control costs, maximize profits, and provide efficient services responsive to market demands -greatest impact on autonomy is b/c of countervailing power of: 1. govt. regulation, 2. managed care system (reduced authority of physicians) 3. corporations in the health care business, 4. changes in the traditional doctor-patient relationship -failure to provide quality care for all Americans -profit motive has bred resentment among consumers and demands that professional power of doctors be reduced -model of professionalism crafted when worked as private practitioner, but now are employees of hospitals/managed care practices -rigid stratification system that promoted increasingly large gap in status between physicians and non physicians has eroded (nurses, pharmacists, nutritionists, physical therapists all can held doctorates in their field) so the medical doctor may be just one type of doctor among many on a healthcare team -although physician remains in charge, the idea of a 'super physician' towering above others on a healthcare team becomes unrealistic when other members of the team know more about their specialties than the physician

Medicare

-federally administered program providing hospital insurance and medical insurance for people aged 65 years and older, regardless of finances -also includes disabled people under age 65 who receive cash benefits or railroad retirement programs and certain victims of chronic kidney disease -specified deductible and coinsurance amounts for which the beneficiary is responsible and limits to the benefits, but most of cost is paid by fed govt. -hospital insurance financed primarily through social security payroll deductions and does not require monthly premium is recipient paid Medicare taxes when working -medical insurance plan is voluntary and financed by premiums paid by the enrollees whose cost depends upon plan selected -covers prescription drug coverage -wide range of plans and options with monthly fee varies according to the plan the individual selects from those available in the state they live in -all drug plans provide minimum standard coverage and those living at poverty line don't pay cost while others with low incomes pay according to a sliding scale -17% of US pop covered -provided needed services for old and established precedent of fed. govt. involvement in health care

What effects patient-physician interaction

-Lack of confidence in physician's technical competence, unwillingness of doctors to spend time, high cost, inconvenient location, long waiting time, unfavorable assessment of doctor's personality -high levels of trust, satisfaction, and participation in decision making are important features in pos. relationship

Government hospitals

-Local, state, federal -less than 4% of hospitals in US

Trends in nursing education

-Traditionally the major source of nurses in US, but college based programs have become more popular with nursing students -1961: diploma schools provided more than 80% of nurses -1970: diplomas school 52% -1970-2014: declined to 3%, moving diploma schools to edge of disappearance -Primary going to associate degree programs, but baccalaureate programs have shown steady gains from 13% in 1961 to 45% in 2014 -Clear trend is toward all RNS having a bachelor's degree, with AD nurses being required to go back to school by hospitals to go RN to BSN (Registered nurse to bachelor of science nurse) -nursing received boost in status in 1980s with nursing shortage in US hospitals (long hours, stress, and low pay reduced attractiveness of field) but enrollment in nursing schools increasing dramatically with higher salaries -image of nursing as a career has been enhanced by ACA which facilitated entrance of millions of patients into national health care system on a regular basis

Nonprofit hospital

-most common type of hospital in US (51%) -controlled by a board of trustees -exempt from federal income taxes and many other forms of local and state taxes -emphasize high quality care for all social classes -dependent on community physicians for staff and referral of patients -large nonprofits are less dependent on local physicians become of higher ratio of staff positions -Medicare and Medicaid accepted -much of money and medicare and medicaid went to pay for doctor and hospital services -public money supports -find it difficult to contend with rising costs and limits on reimbursements from public health insurance -more pressure to sell out to corporate w/ greater financial resources

Broadly describe different types of nursing degrees

3 programs available for RNS: 1. 2 year associate degree programs usually located in junior or community colleges (inexpensive, low time, and place graduates on same track as graduates of other programs; b/c of middle-range level of nursing education, work role has expanded into supervisory and management functions; largest single source of nurses in US); designated 'technical' nurses 2. hospital based diploma schools requiring 2.5-3years of study (was most popular, now accounts for 3% of nursing graduates) 3. 4-5 year university baccalaureate programs (most prestigious , provides training in nursing skills and theory but also background for becoming a nursing educator or leader); designated 'professional' nurses

Trend of CAM use in US

-lack of scientific research to back techniques, but number of CAM practitioners has been accompanied by broad acceptance of many of their therapies by public -allowed to provide services in hospitals/clinics but not part of regular staff usually and only occupy marginal position -Americans spend more than 35 bill. annually on its services and products -dietary supplement industry has flourished since passage of dietary supplementary health and education act by congress in 1994 which allows food products to be sold as cures for disease as long as claims they can actually enhance health are not on the label - can be advertised however in books, pamphlets, and signs where sold -usually middle or working class social background and younger adults use these methods; white women predominantly -excluding chiropractors, role and function of CAM is to meet health needs for those not helped by pro medicine; generally these people are not affluent or well-educated, with exception of middle and upper class individuals who utilize new age therapies and diet supplements

Drivers of medical expenditures in the US: why is healthcare costing so much

-medical practice organized around concept of financial profit in a free enterprise system -advocates: profit leads to enhanced efficiency in providing service, incentive for research and development, and greater responsiveness to patients -opponents: discriminates against those unable to pay, fosters unnecessary duplication of services, and introduces dehumanizing connotation to a service intended to relieve suffering -manner of payment has changed, about 90% of all expenses for hospital services paid by 3rd party sources -3rd party coverage has led to increased hospital admission rates b/c health needs that are met in the physicians office may not always be covered by insurance -hospitalization can reduce patient's direct cost of health care, but don't escape health bills b/c govt. expenditures paid out of tax revenues and private health insurance must also be covered and private companies are set up to make a profit -31% of all money spent on health in US was on hospital services: routine or ancillary costs (room and board, nonmedical supplies, salaries of all members of staff, then labs, OR rooms, X0rays, cast rooms, specialized facilities, cost of med supplies; even if patient doesn't use them, cost of maintaining and operating these facilities for those patients who do use them continues regardless -hospital costs also rise from increased cost for labor, medical equipment, supplies, and new construction -cost of paperwork also significant (would save 50 billion annually if they required less paperwork and had 1 form of all health insurance claims as is done in Canada, but US has govt. sponsored Medicare and medicaid and then numerous health insurance programs and private health insurance companies requiring deductions and copayments and diff. levels of coverage that makes filing claims burdensome) -technological innovations also cause rising hospital costs when used by only a few patients and require training of specialized personnel to operate -public expectations encourage hospital to have most recent innovations regardless if cost effective -rising cost of healthcare due not only to aging of population and demand by growing number of elderly for health care, but also because of increases in hospital expenses and fees for doctors, dentists, and other pro health services -also higher prices for health insurance, wider availability of insurance under the ACA, and rises in prescription drug costs, along with an increase in the number of prescriptions written by doctors, and a shift toward more use of a new, high-price drugs -advertising also drives up drug costs (direct to consumer marketing)

Medicaid

-welfare program -provides for federal govt. sharing in payments made by state welfare agencies to health care providers for services rendered to the poor -gives the states federal matching funds depending on per capita income of state involved -each state required to cover all needy persons receiving cash assistance -states permitted to include disabled and medically need -extended to children under 5 and pregnant women below poverty level (insurance also used to cover people with medical expenses who have no other source of health insurance, not just people on welfare) -Supreme Court ruled in 2012 that states could opt out of expansion and 19 states refused to participate -provided needed services for poor and established precedent of fed. govt. involvement in health care

Different types of nurses

1. Registered nurses: most advanced training and professional qualifications; responsible for nature and quality of all nursing care patients receive as well as for following the instructions of physicians regarding patients; supervise practical nurses and other health personnel involved in providing patient care 2. Practical nurses: beside care of patient, supervision of auxiliary nursing workers, such as certified nurse's aides (CNA), orderlies, and attendants; assist RN by providing less skilled medical care tasks and services designed for overall personal comfort of patients 3. Nurse practitioner/nurse clinician: occupy work position similar to that of physician assistant role; RN trained in diagnosis and management of common ailments needing medical attention; provide some of same care as physicians but are limited in the types of treatment they can provide to patients; may provide much of primary care for patients; gives practitioner more autonomy

Administrative vs. medical staff in hospital and what each is responsible for (p. 343)

Governing body: medical director and administrator Medical director: -includes chief of medical staff, surgical staff, chief residents, etc. -in charge of diagnostic and treatment department services like surgical operating facilities, clinical labs, EKG, X-rays, clinic, emergency and outpatient dept, medical records, and admitting Administrator: -includes director of nursing (assist supervisors, directors, nurses, etc), chief dietician (chefs, bakers, waitresses), assistant administrator management (controller, accounting, receptionist, purchasing), and assistant administrator services (public relations, volunteer, heat, power, engineering, housekeeping, laundry, sterile supply, etc.) -Routine activities of any member in hospital staff initiates a chain of events that affects work of several other hospital employees -although medical director and hospital administrator are linked to the governing body by a direct line of responsibility, they are only indirectly responsible to each other -authority system of the general hospital operates on a dual level -outgrowth of organizational conflict in the hospital b/w bureaucracy and professionalism

Profit hospital

Profit = corporate health care: -in the past have been small and highly dependent on local physicians for references, but trend for profit-making hospitals to merge into multihospital chain owned by a large corporation where physicians are employees of corporation -source of income is internal and generated from patient care, especially private insurance companies -controlled by a board of trustees -higher quality care for patients by staff -profit seeking hospital chains provided attractively furnished rooms, good food, friendly staff, and more efficient services -health insurance pays majority of cost for hospital care, so patients preferred surroundings and more expensive services of the for-profit hospital -physician is an employee rather than an independent practitioner -doctor is bound by rules and regulations of the corporation that is managed by people trained in business, not medicine -about 18% in US -attract patients with private health insurance that will cover cost of profit-making hospitals -can consolidate resources and not duplicate services available elsewhere, thus saving money -however, avoid economically depressed area with high numbers of Medicaid patients or teaching hospitals -corporate medicine provides regular hours and time for a private life which a solo practice can't offer - attractive to new physicians (want salaried jobs, not fee-for service) but then have to meet corporate standards of # of patients see/hour or performance/revenues or lose job -doctors less likely to dominate decision making on policy, budgets, investments, personal appointments, salaries, and promotions

Nurse specialists

i.e. nurse anesthetists, CV nurse specialists, those in AIDS units, etc. have enhanced status and greater autonomy in patient care than do nonspecialists allows nurses to develop, demonstrate, and communicate to physicians their superiority in certain spheres of patient care

Role of midwives in birthing process

two types of midwives: 1. nurse-midiwives: RN assist to deliver babies under the supervision of a physician; often don't need doctor direct supervision but have one on call; legally authorized to work in all states, 13000 in US, increasing use in urban managed care systems to meet demands of consumers desiring natural childbirth and reducing costs; will likely increase as college educated population continues to show preference for less technology oriented births 2. lay midwives: assist births on their own; in home where physicians usually refuse to go; disproportionately serve minorities or those in remote areas or those whose religion prevents use of doctors -earliest forms of care available to women; delivering babies considered women's work -birth attended by midwives dropped as physicians took over responsibility of delivering babies -medical profession adopted strong opposition to midwifery arguing unsanitary and not advanced -by 1950 ceased in US in all but remote areas but has made a comeback despite opposition of medical profession -provide nature childbirth, breathing and relaxation techniques and emotional support in the place of pain-killing drugs and many physicians now practice these techniques -16 states license or register lay midwives, who number about 1,000 in US -to become a midwife, have to show evidence of formal training in midwifery, observe live births, supervise experience, pass oral, written, and clinical exams developed by a nurse-midwife in consultation with physicians