euphemisms in nursing's future

This paper is designed "to tell it like i t is" and "like it is" is buried beneath a massive array of euphemisms perpetrated to deny a future to nurses and nursing. A euphemism is defined as a term alluding to an offensive thing by an inoffensive expression. Seem- ingly harmless words have mushroomed into a euphemistic jargon that includes such remarkable ambiguities, fallacies, and obsolescence as "expanding role, pe- diatric associate, family health practitioner, primary care (Primex product)," and other weird and wonderful cover-ups for the finest euphemism of all -''the physician's assistant". I have the strange belief that what people need is professional and tech- riical nursing services. In fact I am just enoygh of an optimist to believethat nurses are going to wake up from this euphemistic nightmare and declare an honest account- ability for and advocacy of human rights to socially significant health services.

The American health care system is in a notoriously sad state and millions of dol- lars are being spent to try to keep it that way. But"littlepublicsqueals"arearriplify- ing into "big public howls". Vested interest villainies are being exposed. Power. profit, and propaganda -despite their overriding prevalence - are not really socially ac- ceptable motives. What are some of the realities with which nurses must come to grips in order to declare the nature and direction of their commitment? Will it be a commitment to the continuing develop- ment of nursing as a learned profession or will it be a cop out to euphemisms, anti- educationism, and denial of social respon- sibility?

What is really going on? Proposals to prepare physicians' assist-

ants should not have surprised anyone really. In fact t he amazing thing about the whole idea is its 'Johnny-come-lately' as- pect, Kurses have had assistants for dec-

ades. So too have engineers, lawyers, den- tists, master plumbers, electricians, and no end of other experts. Actually almost ev- eryone in contemporary society is busy trying to find himself or herself or itself an assistant. Assistants are very great things and surely assistants to medical doctors are particulariy great things.

The economic value of P.A.'s to M.D.'s is especially notable. How the medical pro- fession could have overlooked such a fabu- lous potential profit for so long seems very strange when one considers the wide vari- ety of other highly productive, dollar pro- ducing enterprises in which M.D.3 engage. Just the little matter of raising medical charges well in excess of other Consumer index Categories' leaves one a little breath- less. And one can only admire the seeming foresight that established grossly in- creased medical charges ahead of the fed- eral deep freeze, thus providing an ad- vanced base for further increases in charges as federal controls were relaxed.' But after ail the Internal Revenue Service has only recently gotten around to investi- gating the exceptional and inflationary prices in the medical-care field's0 perhaps medical doctors should be forgiven for their delay in marketing a physician's assistant.

With a little thought and a few carefully selected references one can find additional reasons why potential profits to be accrued from the services of physician;' assistants may have taken a lower priority. I n a truly team approach by some of :k,?sc: oriented to the novel and innovative 'team way' of providing health services some medical doctors, bankers, and real estate specula- tors have founded a lucrative business in Medicaid Mills.2 Then, of course, there are the many prime, dollar producing invest- ments sponsored by the medical-industrial complex - manifest in a spiralling, self- perpetuating. monopolistic outpouring of

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pharmaceuticals, equipment, and other products guaranteed to delight the most money-grubbing soul and requiring only the turn-table of interlocking participation to assure constant supply and demand - and the dividends roll in.3

Of course some of these recondite ma- neuverings by private and public resources are beginning to be questioned. Like a class action suit was filed in a U.S. District Court February 13,1973which Iinksa’hon- profit” hospital, nine of its trustees, six Washington banks, and savings and loan associations in a conspiracy to overcharge oatients for their own benefit. Could a “dass action” become a “mass action”? Could the proverbial “Philadelphia lawyer” end up busier than the proverbial “one armed paper hanyer with nettle rash”?

The hospital business has done so well that hotels like Ramada Inn, Hyatt House, Sheraton, Holiday Inns and other such in- dustries are already in on the act. And like so many great inventions “it was medical doctors, not management experts, who discovered hospital capitalism.” In fact, proprietary hospitals will net about $90 mil- lion in 1973 on a $1.5 billion gross.5 Ameri- can Medical International sells for $45 a share and has split twice since it was first offered twelve (12) years ago. With only 4th grade Arithmetic and a pencil (blue of course) one finds that 100sharesof Ameri- can Medical International bought 12 years ago fur $225 is now worth $15,600.5 One proprietary hospital netted $74,000 in the first 10 months 8f 1972 from their kidney unit alone and another netted $58,000 on their kidney unit for the same p e r i ~ d . ~

Naturally it isn’t only the proprietary sector of the hospital industry that is finan- cially plump. A few state legislative bodies have gathered their facts, mustered their courage, and garnered their votes to cast out the strangely inappropriate euphe- misms of ‘non-profit’ and ‘charitable’ so cherished by the monolithic non-proprie- tary hospital industry. And who knows - perhaps the taxes recovered by these states can be appropriated back into the hungry maw of some other euphemism - like something called a ‘physician’s assist- ant’. After all it was the famous Dr. Stead of Duke University who quite pointedly stat- ed, “They (physicians’ assistants) were set up to support the present system.’I6

In any event let us turn to the physician’s

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assistant and examine this fine new career dedicated to aiding and abetting the medi- cal doctor in his pursuit of prestigious pre- rogative and assumed privity to erudition. Why there are even some who purport to believe that man’s potential for health is really known only to devotees of physio- logical pathology with a soupcan of psyche to season the soma. And now here comes a ‘sorcerer’s apprentice’ to lea3 the Medical Doctor into an expanded role. Expanded rcles are almost as well known as physi- cians’ assistants but the expanded role for the medical doctor may have strange di- mensions scarcely envisioned by P.A. pro- ponents. In fact it seems likely that the medical profession is scarcely aware of the burgeoning mcial demands and escalating broad based knowledges and technologies that make expanded roles imperative for everybody these days. However the medi- cal profession is a long established field of endeavor so perhaps it can afford to ignore the changes taking place in all directions. Dr. Stead apparently wants P.A.’s to main- tain the status quo and in the January 15, 1975 issue of U.S. Medicine, Dr. C. A. Hoff- man, A.M.A. president, writes, “ I am con- vinced now that there is no health care crisis in this ~ o u n t r y . ” ~ So what are physi- cians’ assistants all about?

The public knows there is a health care crisis. The news media know there is a health care crisis. Nurses know there is a health care crisis. In the last decade doc- tors’ bills have gone up 130% and hospital charges have risen 217%. The average hospital patient pays $100 a day and on up to $175 a day is not uncommon. In the last two years New York City’s Blue Cross plan has jumped 71% and the story is the same across the country.8 But as bad as these figures are they relate to only a narrow segment of health care - that portion which is within the scope of medical doc- tors and hospitals. Society is demanding a wide range of health services that requires the knowledges and skills of a variety of professional fields and which are beyond the ken of medical doctors and hospitals. Could this mean that it is not a shortage of M.D.’s that plagues the nation bu! rather a shortage of professionally educated nurs- es and otner personnel concerned with the real scope of health care?

But back to physicians’ assistants and a quick look at the monetary potential they

hold for their creators. How can they be such an economic asset? Let me give you an example from Sadler, Sadler, and Bliss’s 1972 chronicle of The Physicians Assist- ant: Today and T o m o r r ~ w . ~ This particular physician’s assistant held a master’s de- gree. For outstanding labors (18.8% more patients seen than two pediatricians had previously been able to manage together and with no more office time for the pedia- tricians) this P.A. received the munificent sum of $7,620 (37-46% more than R.N. sal- aries in the same office). There was no increase in overhead or space require- ments. The poor pediatricizns, after all expenses, managed to eke out a mere clear profit of $16,800.

Or let us take the case of a nurse’O who found herself seated in a nationally spon- sored meeting of M.D.’s tightly clasping her little tape recorder that she might pre- serve the plethora of learning she anticipa- ted would emerge. And imagine her sur- prise when this erudite gathering directed its scientific acumen to pursuit of the nurse specialist. For thegrandiosesum of $20,000 it was predicted any nurse would succumb and a four fold profit could accrue to the far sighted M.D. whose potency in the situa- tion would go unquestioned. Needless to say rocks fell from on high in a mighty del- uge upon the listening nurse and her little tape recorder wheri she returned to the hospital nest prattling of power, profits, and propaganda. biow silence shrieks through the corridors and the little tape recorder became a “self-destruct” in no time. But villainy will out - won’t it!

Naturally nurses are high on the list to be seduced out of nursing to be physicians’ assistants. A.fter all a little learning is a dangerous thing and the professionally ed- ucated nurse with a master’s degree in nursing is already a degree ahead of the M.D. - a ghastly threat to all sorts of self- images. To be able also to make a profit out of self-preservation is truly frosting on the cake.

Although nurses seem to be the real pri- ority i n this game-playiog the development of all kinds of physicians’ assistants pro- grams evolve apace. Economic advantages germinate on the home front and in govern- mental closets. Only the M.D. gets paid and with characteristic largesse he dis- penses pennies to the hands and feet that give him time for ruminating upon the hu-

man predicament and the dog-leg on the sixth hole.

Economic advantage is not the only as- set of the physician’s assistant. The P.A. makes a declaration of dependency. His guru no doubt leads him through the intri- cacies of getting answers to simply worded and of course neatly printed questionson a form dedicated to ‘history’ and ‘physical’ data.

The P.A. may learn a range of ‘procedur- al’ tasks and to recall Alfred North White- head, a properly trained person can pick these up in no time. So it is little wonder that Sadler, Sadler. and Bliss do report a training period of one (1) to two (2) years in general for physicians’ assistant^.^ One of the strange inconsistencies that seems to pop up here is that not uncommonly nurses are asked to train these workers. Since nursing is not a part of medicine (despite the eagerness with which nurses may be courted on occasion by the medical frater- pity) the question of just what is being pre- pared arises. Can it be that this new worker is really a nurse’s assistant? Such confu- sion! We should have listened to Florence Nightingale when she wrote, “Experience teaches m e . . . that nursing and mec:icine must never be mixed up. It spoils both.”ll 3erhaps physicians’ assistants should be given the option of becoming licensed as either a P.A. or an R.N. At least these licen- ses would have one thing in common. They identify peer career levels. Both verify preparation for technical practice. Of course there would be the problem for the P.A.-R.N. as to when he would be account- able to the M.D. and when he would be ac- countable to the professional R.N.

After all a valid baccalaureate degree program in nursing preparesa professional peer of the M.D. (and the engineer a9d the lawyer and the social worker, et al.). Asso- ciate degree, hospital school and practical nurse programs graduate nurses who are on an educational par with physicians’ assistants. Now what’s wrong with that? These are all socially significant, equally respectable, first-rate careers so are they not equally worthy of honor? John Gard- ner12 tried to make this point when he em- phasized that equal did not mean identical.

But alas! How often people fail to respect differences. How could society ever get along without pecking orders? Well -why not? Chickens do it, cows do it, sheep do it.

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Even baboons do it. And i f someone can locate a good zoologist it seems likely he could identify some more who do it. Let it never be said that people are different from other animals. But the question still nags! Is this an insoluble problem?

True, American shamans may have some difficulties. After all they are greatly bur- dened with making moral decisions for women who want abortions, declaring the ancient Chinese art of acupuncture their prerogative, countering growing numbers of malpractice suits, struggling to discon- tinue all health services except those pared to the scope of medicine, trying to discover practices initiated by nurses a century ago so they can delegate them back to some naive nurse, clinging gallantly to their own I i cen :;u re w h i I e wit h eq u a1 gal I ant ry I a bo r- ing manfully to get rid of all other licensure - save that which they would certify as limited to the guru’s narrowed goals, joust- ing brevely with national health insurance proposals, and coming to grips with a mul- titude of other equally important endeav- ors. No wonder!tiey need assistants. Sure- ly they have no time to know there is a health care crisis.

How could such diligent persons be ex- pected to know that midwives existed long before obstetricians and that the first pre- natal care in the Western world was initi- ated by the Instructive Nursing Association of Boston in 1901. Or that Visiting Nursing wasestablished in 1877and by 1893“all the social, economic, and industrial conditions affecting the lives of those receiving serv- ices were considered integral to the prac- tice of ‘visiting nurses’.”13 Or that all ac- credited baccalaureate programs in nurs- ing for two decades have prepared family health practitioners. The scope of nursing is markedly largsr than that of medicine. Someone really goofed when they coined the terminological inaccuracy of “expand- ing the scope of nursing”. It’s the wrong way ‘round. It should read “expanding the scope of medicine”. Now there’s a chal- lenge for someone!

But again, let us get back to the physi- cian’s assistant. How should he be viewed? One eminent medical referen~c~states that P.A.’s look like physicians: they wear short, white lab coats and swing stethoscopes. Madison Avenue, beware! It must be the stethoscope that is critical, however, be- cause high school students from coast to

coast may be seen wearing short, white:ab coats. I suppose one might perceive the physician’s assistant as a short, white lab coat and a gyrating stethoscope. Butsure- ly this can’t be all. No, of course not. They are members of the health team - well at least of the medical team (remember that oath of dependency).

Teams are very important. Check the walls of any hospital where personnel may gather. In big print it says here “You are a member of the team” (or some reasonable facsimile thereof). Patients know all about teams too. Sometimes their rooms look like Grand Central Station at 5:OO P.M. on a Friday afternoon. Public health agencies have teams. Clinics have teams. Schools have teams. The team spirit is very essen- tial. Nurses are experts on “team”; so are social workers and psychologists and oc- cupational therapists and nutritionists and a whole horde of other workers. But there is one big difference. The physician’s as- sistant takes an oath of dependency to the M.D. Nobody else does and fortunately so for the poor, downtiodden public. The range of knowledges and competencies needed today for even minimally safe health services are such that no one pro- fessional field is capable of directing or supervising the judgments and decisions of another professional field.

So there is “the team”and everyone says, ”Let’s collaborate”. And it’s just like the dictionary says - collaboration meam working with the enemy. Then someone says, “Let’s set up a committee tostudy the problem” (or in the days of R & D -“Let’s get money from Washington and we’ll re- search it”). And someone else says “We have to get the educators and the practi- tioners together - that’s the whole trou- ble”. Then somebody asks “Snouldn’t tha community be represented in this?” Imme- diately everyone concentrates on the com- munity. This is very popular. It also takes the heat off of everyone else. Besides‘they’ can pick the ‘right’ community representa- tive and internal combustion can proceed at its own pace with a minimum of inter- ference and only a modicum of well regu- lated confrontation.

Strangelyenough thepublis is beginning to show anger. Can it be that they think they’re being done in by inequities, incom- petence, and over-charging? Now really, why shouldn’t the public have to wait three

hours to beadmitted toa hospital? Just be- cause hotels can admit at least three (3) times as many people in a third of the time and collect as many signatures, check out as many credit cards, and validate room space all at the same time is really no ex- cuse for public impatience with the health care system. Hospitals are for sick people. So the next time you have tosit fainting in a hospital lobby for three hours or lie bleed- ing in an emergency room for even more hours just remember - this is a hospital. Your team is waiting (probably in the cof- fee shop)!

Once esconced in a motorized bed (ho- tels and motels have motorized beds too - In fact hotels and motels even have water beds - and sauna baths -and swimming pools - and bar roams - and ice buckets - and stationary bicycles to exercise on - and ad infiniturn) - but back to being en- sconced in bed - a nurse takes your blood pressure, an intern takes your blood pres- sure, a resident takes your blood pressure, your own doctor may show up to take your blood pressure, and now a short white- coated, stethoscope swinging physician's assistant also takes your blood pressure. But do not complain i f your arm is now par- alyzed with a circulatory deficiency. Un- doubtedly there is a biostatistician out by the nurses' station rapidly working a little hand calculator (la?est model in mathemat- ical, technological efficiency) to ge! a mean and standard deviation for all those blood pressures. Thoroughness is the order of the day.

In what I have been saying you may think I have been directing criticism at medical doctors and physicians' assistants, per se. Such an erroneous interpretation would be most unfortunate. Indeed it would only serve to obfuscate the issue. For the medi- cal doctor and his assistant I have the pro- foundest respect. In fact the M.D. expects to be honored, to hcve doors opened for him, to beoblivious to the most obsequious of greetings from lesserfolkwhen he is em- barked upon the arduous demands of his job, to be waited upon, and to have all oth- ers assume a properly vertical position as he hoves into view. Of course these little evidences of the stern fiber of bygone days are diminishing rather rapidly. Physicians' assistants won't be able to add these fatu- ous behaviors to the white lab coat and stethoscope. Indeed Women's Lib is get-

ting rid of all kinds of quaint customs. The physician's assistant is here. So too

has a seemingly unending multitude of health careers multiplied without regard tor human needs or human safety or for the potential employability or market value of the products of these nameless occupa- tions. The public is thwarted, their health jeopardized, and their pocketbooks de- pleted. A massive power struggle is under- way with public demands pitted against a so-called health system dedicated to self- serving obsolescence. Social motivation for emergence of a physician's assistant is abysmally lacking. Norletheless these a- nomalous physicians' assistants (when the dust hasseltled) mayturnoutto beaworth- while addition to the public scene.

In today's career patterns physicians' assistants fit nicely into place alongside engineering technicians, dental hygienists, nursing technicians, dietitians and a host of Dther highly significant and socially es- teemed persons. As a member of the medi- cal team the P.A.'s vow of dependency sets the limits of his practice. But dependency has its rewards.

Recruitment into this fine new career isa masterpiece of game-playing. Con game ingenuities are especially impressive. The potential victims of the con game are se- lected with great care. An R.N. license is a highly desired prerequisite and the con man who corners a degree(s) toting R.N. duly beams with excitement. Here propa- ganda can reallywin him powerand profits, eliminate professional competition, and hopefully diminish public flak about medi- cal inadequacies. Estimations of the po- tential 'take' in this game are very large indeed - well worth the efforts of any good, dedicated con man. Nurses and nursing would be dispensed with. Institu- tions could license but only shamanscould certify. Con game victims would be caught in an iron clad grip without recourse to law or liberty.

Modifications of the old shell game, with words for beans, has been particularly popular as an approach to enticing nurses so that they will leave nursing to follow the drummers of another discipline. Euphe- mistic labels are the coinage used. Nurse clinicians, pediatric associates, family health practitioners, primary care pro- viders (Primex products), child health as- sociates, physician's associates (note that

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apostrophe 3’. It is an A.M.A. symbol for dependencyg), and a growing number of other jargonistic tags have been stuffed indiscriminately into the con man’s bag of tricks. Apparently this particular game is losing some of its appeal. Or else the pros- elytizers think they already have it made. So Sadler, Sadler, and Bliss9 write, “In this book ‘physician’s assistant’ is a generic term which includes a range of mid-level health workers variously named: physi- cians’ associates (Duke and related mod- els), medex, nurse clinicians (pediatric nurse practitioners), child health associ- ates, etc.” Alex Kace:nI3 suggests that the appelation “physician’s assistant” be used exclusively rather than such terms as “phy- sician’s associate”, “n L! rse practitioner”, “medex”, “clinical associate”, ”practitioner associate”, etc. Can it be that the con men are sc) imbued with the magnificence of their own self-image that they deem this confrontation as eminent flattery (some- times defined collclquially as soft soap -- prime ingredient lye).

Now these comments are not to suggest that nurses who want to leave nursing should not do so. Quite the contrary! Nurs- es who want to leave nursing to be sub- sumed under the rubric of “physician’s assistant” should be helped to do so - whether they now travel under a euphemis- tic label of nurse clinician, pediatric asso- ciate, primary care provider (Primex prod- uct), family health practitioner or some other specimen of dubious nomenclature. In fac! it should be a great aid to the poor misled public to simply call physician’s assistants “physician’s assistants”. Such a step should be implemented as quickly as possible.

This would of course openly diminish to some unknown extent the numbers of nurses currently available to meet the cry- ing needs of people. But then nursing could get about its real business of provid- i n g k now I edge a b I e n u i s in g s e r v i c es. Those ccrnmitted to nursing and to the rights of people to receive broad based health services would get on with it. Pro- fessional and technical nurses committed to nursing are alreidy moving to provide creative leadership in evolving a clearly

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new and innovative health system respon- sive to human needs and in which mainte- nance and promotion of health are equally significant with care and rehabilitation of the sick and disabled. Such nursing lead- ership might even allow fora littleoptimism on the part of the public.

Concomitantly if physicians’ assistants are the really fine things that their propo- nents purport to believe they are then cer- tainly their numbers should be increased. Why does not medicine look to the great age of technology for means of multiplica- tion? Do not the characteristics of these products (oath of dependency, short white lab coats, swinging stethoscopes, data storage, etc.) lend themselves to the ma- chine age? With a few good models and a cloning machine an inexhaustible supply of physicians’ assistants could be available on demand. I f really well done the product might be almost indistinguishable from an M.D. thereby quieting any unruly member of the public who might object to paying M.D. charges for robot services. Of course on the other hand there might be those who believed the robot worth more moola than the M.D. (Just look at what computers have done for medical diagnosis).

The public is the real victim in all this game-playing. How long will they permit themselves to be sacrificed to the power, profit and propaganda of head-in-sand philosophers? If nursing’s public account- ability and public advocacy haveanyvalidi- ty then nursing must take steps to assure that tho public is heard. I f there is such a thing as human rights then nursing’s com- plicity in malpractice must cease. I f there is anything to be said for the public’s rights to health services then nursing must take a stand on the widespread, rampant profit- eering that affects the total public and is disastrous for middle and lower income groups. If experimentation without in- formed consent of the individual is immoral ( i t is already illegal) !hen nursing must inform.

‘The physician’s assistant is li red herring. Where will it lead? Who knows?

Where will nursing go? The future is ours to write.

1 "Fees tor Health-Care Here Under Audit by Ihe I.R.S." N e w

L Heallh-Pac Bullelin 43 July-Aupusl 1972

3 Ehrenreich. B and Ehrenreich. J.. The American Healfh Empire. New Yorh Random House. 1970

4 "Suil Claims Hospital Cost is Inflated.'' Washrngfon Posf . February 14. 1973

5Rapaporl. Roger. "A Candle for St. Creeds." Harpers December 1972 p 71

6Health-Pac Bullefrn 46 November 1972. p 16

7 Hoffman. C A , "'Balanced System i s A.M.A.'s Concern." US. hledrcrne January 15. 1973. 2. 29.

8"Your Health Care In Crisis."A Healfh-PacSpecialReporf. hlay 1972

Yorh Times November 19. 1972 9 Sadler. A . Sadler. B . and Bliss. A , Thefhysrcian SASSISI-

an1 Today and Tomorrow New Haven Yale University Press. 1972

10 Journalistic immunity claimed for lhiS one

11 Cope. Zachary. Florence Nrghfi,.gafe and Ihe Docrors

12 Gardner. John €xce/lence New York Harper and Row.

Philadelphia J B Lippincot1 Co. 1958. p 121

Publishers. 1961

13 Dock, Lavinia and Stewart. Isabel. A Short History of Nurs- trig New York G P Pulnam's Sons. 1920. p 161

14 Kacen. Alex. "A Social Viewpoint o l lhe Physlcian's Asslrt- ant Movement. Part I." Physician's Assocrdfe. VoI 2. No 7. July 1972

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an investigation o f the sharissg o f common fears between mothers and their eleven year-old children in middle-class families

Much can be learned about man by ob- serving reactions common to all men. It is especially useful to understand how these common reactions come to emerge, as one moves through the life cycle. One reaction common to all human beings is fear. This study was designed to provide more knowl- edge about the genesis of common fears in children. by examining the relationship between general fearfulness and specific fears of mothers and general fearfulness

and specific fears of their eleven-year-old children.

RATIONALE OF THE STUDY To begin with, it was felt that persistent,

irrational or imprudent fears are a hin- drance to normal growth and development, and to satisfaction in childhood and adult life. I f indeed a relationship were found to exist between mothers' and children's fear-