Who Will Provide the Care?

By Marshall Scott

Last April I was invited to participate in a meeting of the Standing Commission on Health of the General Convention. Those invited represented quite a variety of health ministries and concerns within the Episcopal Church. I was invited as a member of the Assembly of Episcopal Healthcare Chaplains; but participants were from a wide variety of organizations associated with the Episcopal Church.

Early in the meeting the chair, Bishop Barry Howe, asked us to go around the table, speaking of the health care issues that we saw for our society. Again, around the table there were many concerns: universal access to care; the aging population; care for the poor and underserved in a variety of settings and cultures; the rising cost to the Church of providing insurance for clergy and lay employees; and many others. By the time they came to me, I had heard many I agreed with; so I raised one I hadn’t heard, but that I see every day in my practice: the current and growing shortage of physicians and nurses to provide care.

I was reminded of that discussion when I saw the front page of my own Sunday paper. On December 28 the Kansas City Star has this on the front page (one column, but above the fold): “Doctors try to treat physician attrition.” While the story was written with a local focus, it addressed a national problem: “While the supply of physicians roughly meets demand now, by 2025 the nation could be short from 124,000 to 159,000 physicians, according to different scenarios.”

The expected shortage of nurses is even more marked, and arguably more critical. According to the Web site of the American Association of Colleges of Nursing , “The shortage of registered nurses (RNs) in the U.S. could reach as high as 500,000 by 2025 according to a report released by Dr. Peter Buerhaus and colleagues in March 2008.”

There are a number of factors affecting the shortage of physicians. Some are as inevitable and intractable as time: physicians, like all of us, are aging and considering retirement. Some are financial: physician reimbursement keeps getting squeezed, pressed by the weight of Medicare, and followed by insurance companies; and family practice physicians, who provide the most and the most cost-effective care, are paid worst of all. Some are matters of public policy: Medicare is the primary supporter of medical education, including M.D. and D.O. degrees, and has placed a cap on the number of medical school slots.

The shortage of nurses is somewhat different, as the field becomes squeezed between fewer graduates and higher attrition. Research has shown that the primary factors in nurse retention or attrition are about “work/life” – balancing the requirements of the job with personal and family requirements outside – although poor pay (relative to other ancillary health professionals), poor working conditions, and poor relations with physicians contribute significantly. More critically, AACN writes of a shortage of nursing faculty. Finally, the sheer number of education programs for nurses has fallen with the virtual vanishing of Diploma programs, programs associated with hospitals rather than academic institutions.

I wondered to what extent Episcopal institutions are educating physicians and nurses. To begin, I went to the web page of the Association of Episcopal Colleges. There are eleven members of the Association, each with a web site. I reviewed each site to see whether any offered degrees in Medicine or Nursing, or offered Pre-med majors. In fact none offered a major in Pre-med. That wasn’t really a surprise, as that specific major is less common, and most students seeking to attend medical schools were already in other undergraduate majors. Nor did any have an associated medical school (as a graduate of Sewanee, I was aware that there had been one there, now long gone; and that may be true of other schools). So, while our colleges certainly prepare students for medical education, they are not offering those degrees themselves.

Three of the colleges did offer degrees in Nursing. Only one, however, is in the United States. Clarkson College in Omaha offers a Bachelor’s of Science in Nursing, as does Cuttington University in Liberia and Trinity University of Asia in the Philippines. Considering the number of nurses from the Philippines who have come to the United States to work, one might think of Trinity University as also serving the health care needs of the United States (but with even more significant needs in the developing world, that has ethical issues all its own). There was an Episcopal School of Nursing associated with Temple University in Philadelphia, but that program has closed. I would also note that St. Augustine College in Chicago offers a degree for Respiratory Therapists, another profession in short supply. Over all, then, Episcopal institutions have little explicit involvement in addressing the future health care needs we face.

In an essay last year I reviewed the Episcopal Church Annual to get some count of the number of Episcopal health care institutions. I identified seventeen Episcopal hospitals or hospital systems. As far as I can discover only one includes a school of nursing: the Saint Luke’s College, part of the Saint Luke’s Health System in Kansas City (full disclosure: that is the System within which I am a chaplain). This is not to say that Episcopal hospitals are not involved in educating nurses, medical students, and medical residents. Many do participate in clinical education programs in these and other health care professions. However, our health care institutions are no more extensively involved in educating physicians and nurses than are our academic institutions.

In one sense, this might not seem such a big story. After all, there are many other institutions providing education for physicians and nurses, and it would be far easier and more effective to expand opportunities in those existing programs than to try to establish new programs in our own institutions. At the same time, as an expression of our commitment “to seek and serve Christ in all persons,” General Convention has repeatedly supported universal access to quality health care for all in our country. Three resolutions were passed in Convention in 1991 alone (A010, A094, and A099). Moreover, among the purposes of the Standing Commission on Health when was reestablished in Convention in 2003 were:

* Advocating, in cooperation with the Office of Government Relations, for a health care system in which all may be guaranteed decent and appropriate primary health care during their lives and as they approach death;

* Bringing together those within The Episcopal Church who develop, provide, and/or teach health care and health care policy to continue to develop a Christian approach to pressing issues that affect the health care system of this nation;

* Understanding and keeping abreast of the rapidly changing health care market and developments in biomedical research that affect health policy (from 2003-A124)

So, we have expressed our commitment to support universal access to health care, and to advocate for it in our society. However, I would agree with those who point out that “universal access” is meaningless if there aren’t enough professionals to provide the care.

So, how can we contribute to addressing this growing need? We can identify and honor our own members and institutions whose vocations are to provide medical and nursing care, and to educate those who will provide it in the future. We can encourage those who are pursuing professional training to appreciate it as not only a secular occupation but also a spiritual vocation of service. The Church’s Office of Government Relations is already raising health care issues; but we can encourage the Office to include professional education explicitly in their efforts. We can provide in the budget of the national Church resources for the Commission on Health so that the Commission can pursue its mission of leadership. We can advocate ourselves at all levels – individuals, congregations, dioceses, and the national Church – with our civil leadership to pursue universal access to health care for all in the United States, including having enough professionals, and providing them sufficient support, financial and otherwise. We can especially acknowledge that we who can are willing to pay for those professionals and those resources so that care can be provided for those who can’t.

For all the interest expressed in last year’s election rhetoric in expanding access to health care, the crashing economy has tended to sideline any other issues, including those like health care that are arguably related to industrial growth and economic recovery. We can take steps both within and without the Episcopal Church to keep one important issue from simply overwhelming another, and to keep alive the call to make access to health care universal – indeed, to see it as a civil and human right. We have a particular opportunity this year, as we will be gathering in General Convention, the one gathering in which we speak as a whole church. However, the first step to take is to recognize the problem. Once we’ve done that, raising our voices is much easier. And unless we do both – recognize the problem and raise our voices – we may discover that the care we need simply isn’t there.

The Rev. Marshall Scott is a chaplain in the Saint Luke’s Health System, a ministry of the Diocese of West Missouri. A past president of the Assembly of Episcopal Healthcare Chaplains, and an associate of the Order of the Holy Cross, he keeps the blog Episcopal Chaplain at the Bedside.

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