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10 The Results of the Medical Monopoly “A Regulatory and Policy-Making Quagmire” By the end of the twentieth century, the results of the centuries-old medical monopoly were singularly unimpressive. In this chapter, focused on the last decade of the twentieth century, we consider nurses’ and consumers’ critiques of the health-care “system,” discuss the efforts at reform by nurses, and document the continued rejection of nurses’ autonomy by organized medicine. The politics of government efforts to reform health care and their impact on nurses are analyzed, particularly the Clintons’ national health-care proposal and its collapse. With the election of a conservative Congress came an attack on social-entitlement programs; women and children were disproportionately affected. Following the lead of the political conservatives, organized medicine formally rejected advanced practice nurses’ autonomy and actively lobbied to overturn the antimonopolistic rulings by the Federal Trade Commission. In the absence of a national health care system and a rise in hospital and agency mergers, health maintenance organizations (HMOs) and profit-making corporations gained ascendance. Hospitals and other health agencies sought to reduce institutional costs by introducing minimally trained unlicensed assistive personnel (UAPs) to replace RNs. Efforts were made to eliminate primary-care nursing and reintroduce a form of functional nursing, to shift from state nurse practice acts to institutional or other forms of licensure, and to create multi-discipline professional regulatory boards instead of boards of nursing. Modification of existing nurse practice acts to foster greater autonomy continued to be challenged by medical societies and physicians; in its resolutions, the American Medical Association (AMA) equated collaboration with supervision. The possibility of nurses organizing to gain more power to deal with the changes in the delivery of health care was substantially weakened by a Supreme Court ruling in 1994 that defined most nurses as supervisory or administrative personnel, thus limiting their rights to organize in unions to improve their work conditions and control at least some aspects of patient care. Though the National Labor Relations Board (NLRB) ruled in 1996 that staff and charge nurses were not supervisory personnel and were thus protected by federal labor laws, many institutions attempted to ignore this ruling. Despite all these negative shifts, the research continued on nurses’ quality of care compared to that of physicians, confirming the positive findings from the mid-1960s onward. With support from foundations, APNs moved to create , sometimes with physicians, community-based health care centers and to The Results of the Medical Monopoly 397 expand their own nurse-controlled health centers. Yet the medical monopoly, given the collapse of the Clintons’ national health-care program, seemed stronger than ever; therefore, the twenty-first century would probably be marked by the continuing struggle of nurses to gain even moderate autonomy. Gender, although still critical, received less emphasis as increasing numbers of women became physicians and more women nurses and medical technicians became physician’s assistants. By 2000, 27 percent of physicians were women, but nurses did not perceive women physicians to be substantially different from men physicians in their behaviors. However, women physicians reported that they still experienced sexist and discriminatory behavior. For example, in one of many reported cases, Dr. Frances Conley, a neurosurgeon, quit her tenured professorship at Stanford University Medical School in 1991, saying “she was fed up with demeaning comments and unwelcome sexual advances from male colleagues” (Conley, 1991). In a letter to the San Francisco Chronicle, she wrote: “Even today, faculty are using slides of Playboy centerfolds to ‘spice up’ lectures; sexist comments are frequent and those who are offended are told to be ‘less sensitive’; unsolicited touching and fondling occur between house staffs and students, with the latter having little recourse to object . To complain might affect evaluation.” Though Conley returned to Stanford as professor of neurosurgery in 1993, she noted that sexual discrimination and harassment toward female physicians and medical students were still evident : “you’re not going to have the brash-type discrimination that women in my generation saw, but the verbal taunts, verbal degradation is going to continue ” (Manning, 1998, p. 1D). Conley’s perceptions were supported by Lynn Nonnemaker’s recent study of women physicians who, although 10 percent more likely to pursue a career in academic medicine, were 26 percent less likely to be promoted, with few advancing to full professorships (De Angelis, 2000). Clearly, simple increases in numbers of women physicians or PAs were not an adequate...

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