Nurses providing geriatric care have been perplexed by their relationship to physic ians who are medical directors in skilled nursing facilities. Since the day when a Department of Health, Education, and Welfare regulation made it mandatory, the role of a medical director on the staff of a skilled nursing facility has been surrounded by confusion and strongly held conflicting concepts of the role. Nursing home administrators wanted physician participation in the care of patients within their facilities, however, they were not prepared for the regulations that required formal appointment of a medical director. Neither did they fully appreciate the enforcement responsibilities placed upon them as administrators relating to the employment and utilization of a medical director.
Physicians were not enthusiastic about becoming medical directors. Individually, as physicians, they felt a personalized sense of responsibility for their own patients. When asked to be medical director of a nursing home, the same physicians were faced with unpleasant choices.
By training, a physician is primarily concerned with the illness and health of a human being. However, when presented with a range of patients, the older ones, especially those in nursing homes, tend to fall low on a physician's list of priorities. A regular visit to a nursing home, especially if it is characterized by the phrase, "paper compliance," is elften seen as a task that should be delayed if possible.
Fortunately, that circumstance shows hope for a positive change. Now, we observe physicians who are increasingly recognizing the scientific complexities of care provided older nursing home patients. Many of the lessons being learned by physicians come from long-term care nurses.
As an example, a project conducted by the Mountain States Health Corporation with funding from the W.K. Kellogg Foundation believes that the geriatric nurse practitioner-physician team is the key to quality improvement in nursing homes.1 During the past 2% years the project has been instrumental in stimulating the education and placement of 24 geriatric nurse practitioners (GNPs) on the staff of skilled nursing facilities. Each of them works with at least one physician in the northwestern United States to provide services to facility residents. In each location, one person who has been involved in the success of this project has been the medical director of the nursing home. Usually, it has been with his support that the GNP-physician team concept has been successfully introduced.2
In the course of this demonstration, the project staff interviewed the director of nursing service, the director, and the administrator of 25 participating facilities to determine the attitudes of the facility leaders. We sought their individual expectations of what a GNP would do in the facility and how she would relate to the staff and the medical director. With advance knowledge of role perceptions, we anticipated that the GNP could better plan her entry into the nursing home staff.
As a corollary, the three leaders (director of nursing service, administrator, and medical director) of each facility were asked how they perceived the role of the medical director. We searched for attitudes that might help define the role of the medical director. In turn we wished to know how those attitudes would affect the future relationship of the medical director and the GNP. Responses reflected the respondents' experience with the existing medical director and also their expectations. The wide range of responses were analyzed and sorted into nine categories of activity comprising the medical director's role.
Three categories of activity stood out as major responsibilities based on the frequency with which they were mentioned. These are:
1. Administrative and supervisory activities;
2. Liaison between practicing physicians and the nursing home including compliance with regulations; and
3. Provision of direct patient care.
The first of these, administration and supervisory activities is described by the following sample of comments.
Directors of nursing service viewed the medical directors as: "making out policy"; "advisor"; "meets regularly, he approves policies"; and "helps with legal problems with patient charts."
Medical directors described their administrative role in slightly different terms: "policy establishment with the administrator and director of nursing service"; "supervision of medical care, coordinate medical care"; "generally on overseer to insure jobs are being met-view these from a physician's perspective"; and "administrative function between nursing home, administrator and patient."
Administrators expected the medical director "(to) assist in developing patient care policy"; "(to be) an assistant administrator supervising the medical portion of the operation"; "attend committee meetings"; "supervise medical services"; and "identify problems, procedures, or supplies." Other descriptions included "describe patient care deficiencies," and "(be a) resource person for the entire staff."
By far the most frequent number of responses were included in this category of administration and supervisory activities.
The next most frequently mentioned activity was in the area of liaison between physicians and the nursing home. In this category we observed differences of response that are based upon the individual's education and his/her organizational responsibility.
Directors of nursing service saw the medical director as: "assisting SNF staff in dealing with physician problems"; "(he) persuades other physicians to follow patients or sees them himself-visits facility every day"; and "help the SNF with doctors who are not cooperative." A candid comment was: "(he) doesn't like bureaucracy; doesn't do much in the medical director role; could be instructive to staff regarding medical problems," and finally, "helps with problems with other physicians by giving advice and direction."
Medical directors said they, "advise administrator on how to approach other phyicians," and "persuade physicians to write their records; sends letters; some refuse to come; if they don't visit home he arranges to see patients for them." Others added, "(the medical director is in) medical politics," and "when the medical director notes attending physician deficiencies, he asks the director of nursing to make a report."
Administrators described the medical director as, "a peer person to encourage MD participation"; "prod other physicians, as between the physicians and the nursing home"; "function as a friend of the nursing home in a less than friendly professional community"; and "set an example for other physicians regarding appropriate attention to geriatric patients."
It is clear that two of the three groups of respondents in this category of activity expected the medical director to be the major liaison between physicians and "the nursing home" and enforcer of regulations requiring regular physician attendance in a nursing home. Medical directors tended to see their role somewhat similarly but, perhaps by responding less frequently, did not refer to the less than pleasant task of persuading their peers to action when necessary.
The third major category of activity perceived to be within the responsibility of a medical director relates to providing direct patient care.
Directors of nursing service said, "We need physical exams and patient evaluations." One medical director was described as, "having a great number of patients; other physicians transfer patients to him; he also inherited many patients from the previous medical director; he approves house orders but rarely covers for other physicians." Other nursing directors' comments were, "(he) sees all patients; always available," and "if a physician is not meeting regulations or if a patient is not well managed medically, we need a second opinion; he accepts patients who have no physician." One thoughtful director said, "he makes weekly visits to take care of problems; he should see patients and write orders on any patient in the nursing home, reviewing problems (duplications) and orders."
The responses from medical directors had a slightly different quality though some considered they had a direct patient responsibility. For example: "the medical director is not expected to act as a physician"; "no direct patient care"; and "patients are the responsibilities of attending physicians." Other physicians expressed a contradictory view of the role of the medical director. These included: "accepts referrals from physicians, the administrator, and the Veterans Administration," and "available for emergencies in chronic care; provide primary care; sees all patients except Dr. X's." "(He) is paid as a medical director and doesn't charge patients; is responsible for the care of patients," and "uses AMA guidelines; sees patients of other physicians if necessary."3
Some administrators clearly anticipated that the medical director would become involved in some aspect of personal services for nursing home patients. One administrator anticipated the medical director would, "substitute for private physicians when they don't participate." Another commented, "(he is) available for emergency consultation." The consultation aspect was mentioned four times by administrators. Other comments included: "a resource in dealing with a medical problem, for example, infection," and "manage a patient when necessary." One administrator indicated that the medical director was, "not needed to care for patients."
In this summary form it is evident that there is little commonality in the expectations of a medical director. It is essential that the GNP consider carefully these perceptions as she establishes her role in a facility.4
The remaining six activities that were perceived to be a part of the medical director's role were mentioned less frequently but deserve attention.
The next category of responses reflected views of respondents who said that, "we have a medical director because we are required to by federal regulation."
Medical directors observed that: "(he) fills legal responsibility"; "meets regulations of red tape and bureaucratic requirements, signs papers"; "knowledge of rules, regulations, etc, to assist nursing home in meeting state and federal standards"; and "minimal involvement, doing it only because it is required."
Administrators noted that "he is required," ".. .especially to enforce federal regulations regarding physicians," and "paper compliance." Interestingly, directors of nursing service did not mention this category.
The next category, not needed, is disturbing in that it records ten responses reflecting either a position that the medical director is not needed or that they did not know what the medical director is expected to do.
Directors of nursing service added, saying, "unclear," "we could use help in how to utilize our medical director," and "doesn't know what he is supposed to do."
Three medical directors responded: "A fifth wheel"; "no idea, new at it, need information",; and "don't know."
Administrators commented: "not sure of the role of the medical director"; and "don't see the need for a classical medical director." One said emphatically that "this is not a medical facility, this is a nursing home; the position is considered 'director of medical care.' "
Looking at a brighter side some respondents saw an important role for the medical director in offering continuing education to the nursing home staff. This aspect of a medical director's role was mentioned by seven directors of nursing service and two administrators.
The medical director's role in assuring a high quality of care was mentioned by one medical director who commented, "(he) exists primarily to see that good care is given-though his authority is limited." Two administrators supported that view.
The administrator group was the only one that mentioned a category of activity relating to patient care planning. Three of them added comments such as, "participates in patient assistance in discharge planning," and "future care planning."
Finally, only one administrator referred to the relationship between a medical director and a geriatric nurse practitioner. He observed that, "he wants the medical director working with the geriatric nurse practitioner."
Nursing homes exhibit the same problems of communication, authority, and goal setting that are common to all organizations that bring together a variety of disciplines for a central purpose. Too often that central purpose is obscured by a lack of understanding of institutional goals and inadequate definition of tasks and delegation of responsibilities. Perceptions of the role of a medical director reflect those kinds of differences.
HEW regulations imposed on the operation of nursing homes have created an atmosphere that is repugnant to many physicians who characteristically resist imposition of external authority. Nonetheless, it is unlikely that the requirement for a medical director in a nursing home will be entirely abandoned though it may be modified by utilization of a geriatric nurse practitioner, not as a substitute for, but as a part of a GNP-physician team.
The project staff reporting these observations strongly recommends a clearer definition of the medical director's role. The role should move toward one requiring a primary responsibility for direct patient care of all patients in a facility, working in concert with a GNP. The vague existing perceptions of the role-enforcer, middle man, "committee attender," consultant- should be distilled down to providing direct patient care and serving as a knowledgeable resource person available to the nursing home staff. This direct simplification implies that there will be one or two physicians with a GNP caring for virtually all patients in a facility. We believe this plan will: (1) improve patient care because the physician with a larger patient load is likely to become better prepared and experienced-an expert; (2) working relationships between a GNP and only one 01 two physicians will be close, characterized by trust, confidence, and knowledge; and (3) remove the onerous qualities of the present medical director role and establish a sound, patient-centered objective as a basis for a satisfying professional experience.
Revising the medical director's role to one of active participation in patient care is a task that is best done jointly by the administrator, medical director, and director of nursing service-the key leaders of a nursing home. Combining a GNP with a medical director in a service team offers the best hope for quality improvement in nursing homes.
- 1. Brody SJ. et al: The geriatric nurse practitioner: A new medical resource in the skilled nursing home. J Chron Dis 29:537, 1976.
- 2. Joint practices: A new dimension in nurse-physician collaboration. Am J Nurs 77(9): 1466, September 1977.
- 3. Moss BB: Medical direction in long-term care facilities. Ill Med J September^. 1973.
- 4. Greetiburg BM: Medical model- Nursing model? A gerontological dilemma. J Gerontol Nurs 1:6. September October 1975.