Socy 3052 exam 3

Nurse Characteristics

-Technical knowledge needs physician approval -Typically assist doctor in diagnosis and treatment -Subordinate to and work at request of doctor -Have less prestige than doctor

Prestige factors (hall)

1. Hospital affiliation -More prestigious hospitals provide better-paying practices -Best residency •Program reputation and location •Internship in same community for planned practice •Friendships, professional networks 2. Clientele -Lay referral (family, friends, neighbors, coworkers) •Discuss Drs.' behavior, diagnosis, prescriptions •Reputation, popularity -Professional referral of patients -Hospital connections -Managed care restricts referrals 3.Inner Fraternity

Golden age of Doctoring

1950's -High professional control -Increasing prices and overcharging -Unnecessary tests, hospitalizations, prescriptions, operations -Provider-structured insurance paid for most mistakes -Major growth industry

Patient Advocates

Advocating for patients through rights or privacy

Early ineffective techniques

Before 1850 •Many techniques ineffective, painful, dangerous, or fatal Bloodletting -could weaken condition Purgatives -caused vomiting Cholera treatments -ineffective •Some more recent treatments questionable

Rules of Etiquette

Discourage criticism, accountability

Dr. Kim Patterson

Effect of social and psychological factors on health and longevity -Impacts on life expectancy -Impacts on incidence of disease -Effects on prevention and treatment and choices patients make in these areas

Louis Pasteur

Germ theory -Louis Pasteur, France, mid-1800s

Free Standing emergencey centers

Individually or federally owned separate from hospitals.

Six stages of socialization

Initial innocence -desire to care for patient -But feel inadequate •May be assigned minor tasks, such as making beds •Labeled recognition of incongruity -Disconnect between training and expectations -Collectively articulate disappointment -Openly question their choice of becoming a nurse •Some drop out of school •Psyching out -Anticipate instructor's intentions and focus on these •Role simulation (end of 1styear)-Perform so as to elicit favorable responses from instructors •Provisional internalization •Stable internalization -Identify as professional nurse

Nurses

Largest Group of US Health Workers Majority 70% work in hospitals •Originally a religious activity •Roman Catholic nuns practiced nursing -Hospitals generally for poor until late 19th century -Form of charity, a calling -Did not work under doctor supervision -Could refuse to treat patients •Unwed mothers, individuals with STDs

Licensed Practical Nurses

Licensed Practical Nurses -care of patients at their bedside -may supervise certified nurses aids, orderlies, attendants.

Government regulation

Medicare and Medicaid legislation in 1960s -Provide for elderly, poor •Opposed by AMA

Gentleman's agreement

Overlook mistakes of others -Technical errors made in good faith less concerning Moral errors- unreliable, uncooperative, more concerning Subject to sanction

Physician assistants (PAs)

Qualifications -Bachelor's degree, previous experience -Complete 26-month training program •Similar to master's degree -75% were women -$98,000 average annual salary in 2015 •Licensed to practice medicine, but under physician supervision •Provides primary medical care

Trends in doctor-patient relationship

Social Status Control over patient

Asylums (Erving Goffman)

an institution offering shelter and support to people who are mentally ill.

Geri-chair

are large padded chairs with wheeled bases, and are designed to assist seniors with limited mobility.

Hierarchy of needs

self actualization esteem love/belonging safety psychological

Features of professionalism (Goode)

• Two basic characteristics -Prolonged and specialized training -Service orientation •Consolidate professional power with -Public accepts claims of competence -Profession controls membership rather than outside authorities

Physician socialization

•145 accredited U.S. medical schools accepted -20,631 out of 52,550 applicants (39%) in 2015-16 •1styear students -48% female, for greater diversity -49% non-white in 2011, for greater diversity -Aged 21-23 typically -3.6+ undergraduate GPA -Majored in biology, chemistry, psychology, premed -Most from middle and upper classes, although changing -High probability of obtaining M.D. degree -May benefit from having close family member, friend as M.D. -Want to help people

Early practicing physicians and their training

•854,698 medical doctors (MDs) practicing medicine in 2013, U.S. •Before American Revolution -Doctors often ships' surgeons, apothecaries, clergy •Some gained medical knowledge in Europe •University of Edinburgh in Scotland provided best training •College of Philadelphia, 1765 -1stmedical school in America •Rapid increase in medical schools after 1800 -Quality of schools and of doctors low until 1850

American Medical Association (AMA)

•AMA Founded in 1847 in Philadelphia - 15% of qualified physicians were members in 2011 • 79% of qualified doctors were members in 1963 -nonmembers dont need benefits • Armed forces, researchers, universities, government -Central interest as proactive trade association, or in public welfare •Special societies are growing -American college of surgeons and physicians

AMA guiding principles

•AMA Guiding Principles -Physician is independent practitioner Free of control of public & Fee for service medical practice

Work Environments

•Academic medicine •Private practice: solo or partnered; concierge •Multi-specialty group practice: private versus HMO setting (Kaiser) •Veterans Affairs Hospital •Military •Outpatient versus hospital-based primary care •Loan repayment options •Other: hospital administration, pharmaceutical company, politics, med

Nursing Degrees

•Associate degree (AD) -Faster, cheaper -Vocational rather than professional programs •Designated "technical" rather than "professional" -Supervisory and management roles expanding •But roles may surpass their training -Largest source of U.S. nurses •Some hospitals require bachelor's degree -Schools offer training programs for folks with ADs •"Registered Nurse to Bachelor of Science Nurse (R.N. to BSN)

Nursing Education

•Attractive for many women (and some men) •Three types of RN programs -2-year associate degree (AD), usu community college •52% of nursing graduates in 2014 -2.5 to 3 year hospital-based diploma schools •3% of nursing graduates in 2014 (may soon disappear) -4 &5 year university programs (bachelor's degree) 45% of nursing graduates in 2014

Diagnostic related groups (DGR's)

•Diagnostic related groups (DRGs), early 1980s -Government fee schedules for Medicare patients Ceiling on how much government will pay

Pharmacists

•Doctor of Pharmacy (Pharm.D.) -only degree now available (used to have B.S. Pharmacy) •6 years past high school •Roles-Fill and dispense prescriptions, other medication -Provide advice and instructions about drug use •Effects, dosage levels, how to use •Need authorization from doctor to dispense drugs •Practice in -Hospitals, clinics, pharmacies

Changes in status of doctors

•Early 20th century -Physicians had solo practice, were independent, and charged fee for service •Now, dominance of med. profession declining -Doctors employees in hospitals or managed care practices -Smaller gap between physicians and other health care personnel •Some nurses, pharmacists, physical therapists, nutritionists have doctorates

Managed Care

•Health Care Organizations, Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs) -Control costs -Monitor doctor's treatment -Limit referrals to specialists -Require authorization before hospitalization -Doctor's authority reduced •Work within fee structure, regulations •Patients pay monthly fee for care -May also pay copayments for services •Care could be stable, reliable, less costly •Primary care physicians

Inner Fraternity

•Inner core -Knowledge elite (physician-researchers) •Research productive sign of influence -Clinical trials -Administrative elite (physician-administrators) •Medical school deans, department chairs, heads of clinics -Oversee budgets, staff, other faculty •Most prestigious positions -"Academic appointment in university medical centers of large urban areas" Study the chart

Medical Education

•Learn -Emotional detachment •Businesslike demeanor •May depersonalize patients -Authority and autonomy -Tolerate uncertainty •Can't learn everything •Medical knowledge and techniques are limited •Difficulty in distinguishing between the above two forms of uncertainty

Registered Nurses (RNs)

•Licensed registered nurses (RNs) -Follow doctor's instructions to care for patients -Supervise practical nurses

Errors in Medicine

•Malpractice relatively common -Few hundred in 1950s -10,000/year in 1980s -Peaked in 1988 and has since declined •Cost of malpractice insurance has declined -States set limits on size of malpractice settlement •Data bank on incompetent physicians -Disciplinary actions and malpractice awards •Medicare and Medicaid fraud

Iatrogenic effects

•May be due to -Unsafe procedures -Transmit infections -Over-or mis-prescribe drugs -Amputate wrong leg, breast -Leave instruments in body after surgery •Alabama, 2007-08 -Doctor liberally prescribed painkillers and sleep medications •Several patients died -Lost medicine license

Factors in weakening medical profession

•Medical profession weakened since beginning of 21st century -Oversupply of doctors -Government regulation -Employers who pay for health insurance -Third-party payers -Changes in doctor-patient relation

Alternative Tracks

•Mid-level provider: ANP (advanced nurse practitioner) or PA (physician assistant) •Advantages •Less time to complete education •Less cost of education •Many nurses start as RNs and progress to BSNs and NPs while still working; companies such as Kaiser Permanente have programs to pay for their education while they are employed •Disadvantages •Less autonomy (must practice under a physician)

Doctor-nurse game

•Nurses do not directly challenge doctor's orders -Informal interaction -Supports doctor's authority, nurses subordination •Nurses indirectly make recommendations -Patient experienced death in family, unable to sleep •Doctor indirectly asks for recommendation -What has been helpful previously? -Both save face »Nurse seen as great at her job »Doctor seen as competent with patients and staff

Doctor-nurse relationship

•Nursing largely comprised of women -Subordinate to doctors •Nurse-physician inequality is declining -Better training of nurses •E.g., bachelor's degrees, & Doctor of Nursing Practice (DNP) -Nurses becoming more assertive -More male nurses •6% of RNs -More female doctors

Florence Nightingale

•Nursing role changed in middle of 19th century •Nightingale English Protestant •Trained as nurse in Germany •Founded hospital for "Sick Gentlewomen in Distressed Circumstances" in 1853 in England •Brought honor, respect, code of behavior to occupation

Nurse Trends

•Nursing was less attractive because of -Low pay, long hours, low status, stress •Status and income increased in late 1980s •Increasingly drawn from middle, upper class -Seen as solid middle class occupation •Increasingly viewed as long-term career •Affordable Care Act may increase nursing

Midwives

•One of earliest forms of care for women •Assist mother in childbirth •Two types -Nurse midwives •Supervised by physician -Lay midwives •Assist on their own •Deliver babies in the home •Licensed in 16 states •Midwives attended -Virtually all births in colonial America -Half of births in 1900 -Exceptionally few births in 1950 •Medical profession argued for hospital deliveries -Surgical skills, access to drugs, sanitary conditions •Resurgence of midwives for -Natural childbirth, home deliveries, drug-free deliveries •Includes middle-class women

Flexner Report

•Only three medical schools fully approved -Harvard, Johns Hopkins, Western Reserve •Recommended schools should have -Full time faculty -Lab and hospital facilities available to students •Med students should receive education in -Natural sciences •Resulted in closure of -Women's medical schools -6 of 8 African American medical schools Carnegie foundation

Professional Standards review Orgs (PSRO)

•Professional Standards Review Organizations (PSROs) -Established in 1970 •Review medical care of Medicare, Medicaid patients

Evidence based medicine

•Proven diagnostic and therapeutic procedures -Can result in •step-by-step instructions for medical care -Reduces uncertainty -Requires applying evidence to individual patients from large clinical trails & population-based studies •Can increase uncertainty

Gate Keepers

•Screens patients before referring for expensive procedures and specialists -Treatment may be delayed or denied -Can be disciplined for excessive spending

Nurse Practitioners

•Similar to physician assistant -$95,000 average annual salary •Often supervised by off-site physician who's on call •May be increasingly common with -Affordable Care Act -Primary care centers in retail stores (Target, Walmart, CVS) •Treat -Minor injuries, heath problems -Flu shots -Manage chronic diseases -Prescribe medications (in all 50 states) -Controlled Substances in some states

Transitions in healthcare delivery

•To system shaped by consumers and profits from one run by doctors •Decline in public trust of physicians •To emphasis on primary care and prevention rather than specialization and subspecialization •To more outpatient care in doctors' offices and homes, rather than hospitals •To payments based on detailed accounts rather than fixed prepayments •Managed Care systems -Doctors are employees

Double Agent

•Work for patients and managed care organization -Become patient advocates for specialized care