1. Short, Nancy DrPH, MBA, RN

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After almost 30 years as an RN and nursing school professor, I had the chance to spend a year as a health policy fellow on Capitol Hill. Having earned a doctorate in public health, concentrating on policy and administration, I wanted to see firsthand how ideas make it to Congress and move through the legislative process to become policy or law. The fellowship was in many respects a life-changing experience-and allowed me to contribute the often overlooked perspective of nurses to the policy-making process.


One of six Robert Wood Johnson Foundation health policy fellows selected for 2004-2005, I was the only nurse, and only the ninth nurse to be selected since the program's inception in 1973. My fellowship began in September 2004 with a 10-week orientation designed to acquaint fellows with the legislative aspects of policy development. I met numerous government officials, analysts, advocates for various interest groups, health care futurists, researchers, and representatives of health care philanthropies and the media. The orientation process fulfilled my objective of building relationships with decision makers and opinion leaders.


After the orientation, fellows go on a series of two-way interviews with various congressional offices. I found a good fit with the office of U.S. Senator Bill Frist (R-TN). Because of his position as majority leader, I'd learn how the nation's health policy agenda is set. And because he was a physician, I'd be working for one of Congress's health care experts.


My assignment to Senator Frist's health team began in January 2005 with a staff retreat to determine priorities for the 109th session of Congress. Among these were initiatives in improved health care quality and global health that Senator Frist intends as his personal legacy. I was assigned a portfolio of issues to research and monitor, including the following:


* preventive health care (reduce obesity and methamphetamine use)


* global health (ensure clean water worldwide and create a global health corps)


* health care quality (work toward eliminating disparities)


* legislative reauthorizations and revisions (the Trauma Care Systems Planning and Development Act of 2005 [S 265] and the Ryan White CARE Act)



This list steadily grew as issues of interest to the senator emerged. My duties included conducting basic research, collaborating with other senatorial staffs; contacting speakers for briefings; and on occasion, testifying before commissions as Senator Frist's representative. I also helped write legislation, in one instance combining the legislative language from a health-disparities reduction bill introduced by Senator Frist with a comparable one introduced by Senator Kennedy.


The issues are often complex, but experts tend to make themselves available to congressional staff on short notice. An example from my own institution is Joanne Kurtzberg, MD, director of the Pediatric Blood and Marrow and Transplant Program at Duke University Medical Center in Durham, North Carolina. Kurtzberg came to Washington three times while I was a fellow to assist congressional staff and members in developing regulations for umbilical cord blood banking and registries.


I became aware of several research resources and learned how busy members of Congress stay abreast of policy developments. The Congressional Research Service, for example, provides analyses of issues, side-by-side comparisons of proposed legislation, and background articles for congressional staff and members. I called the research service one day to find out the history of funding for trauma systems development in accordance with legislation passed in the 1990s. Within two hours, I had the information I needed. Congress members and staff can check out materials from the Library of Congress; they also have online access to databases such as LexisNexis and maintain subscriptions to numerous publications.


Fellows can also pursue issues of particular concern to them. I became interested in medical air transport after a staff meeting with constituents from the flight team at Vanderbilt University in Nashville. They discussed the rising costs of medical air transport, related reimbursement policies, the proliferation of for-profit medical evacuation companies, and the quality of care provided in this largely unregulated industry. I also learned of an upsurge in "subscriptions" to commercial emergency medical services and the possible implications: costly and possibly unnecessary use. After further research, I wrote a report for Senator Frist, and this issue may be addressed in the Health, Education, Labor, and Pensions Committee's report on the Trauma Care Systems Planning and Development Act of 2005.


Another issue that regularly came to my attention was the attitude in Congress toward nonphysician clinicians. A typical experience came at a March 2005 meeting with nurse constituents from Tennessee. I went to the meeting with a 23-year-old legislative assistant whom I'd turned to for advice from time to time during my fellowship. The nurses, among them the deans of two schools of nursing, an associate dean for practice, and two NPs, were seeking Senator Frist's help in changing federal regulations so that nurse-managed clinics could be reimbursed under the same rules as federally qualified community health centers. (Clinics staffed by advanced practice nurses frequently aren't paid for providing care to uninsured patients; health centers are.) The nurses gave a well-organized, concise briefing, strongly supported by evidence, on the clinics' services to people who are poor or uninsured. But my young colleague was skeptical that nurses could autonomously provide adequate care. As we walked out of the conference room, she leaned toward me and said, "We'll have to check out their story. I don't see how it can all be accurate." As we chatted, it became clear that she simply did not believe nurses could perform the described services without physician supervision.


I resolved to take every opportunity to promote the nursing perspective as a counter to what I saw as a physician-centric bias among congressional staffs. At age 51, I was by far the oldest member of Senator Frist's health team as well as the only person with clinical experience. In meetings of the health team, I suggested inclusive language such as "clinicians" or "providers" as a substitute for "physicians" in legislative proposals, position papers, and speeches. I believe I influenced some staffers' thinking, but physician dominance remains a strong tradition in Congressional culture.

FIGURE. Author Nancy... - Click to enlarge in new windowFIGURE. Author Nancy Short by the Capitol in Washington, DC, where she served as a policy fellow in the office of Senate majority leader Bill Frist.

After the 12-to-16 month assignment, fellows typically return to their home institutions, though some catch "Potomac Fever" and find jobs in government or government relations. I chose to return to my faculty position at Duke University. But I'm a very different person as a result of my experience on Capitol Hill. Politics and policy no longer seem so mysterious to me. I read the newspaper differently and understand nuances in news reports that I never caught before. I find myself glued to television coverage of government-inaction such as Face the Nation and C-SPAN. I'm better equipped to teach, talk, and write about health policy.