C omposing a Life by Mary Catherine Bateson was a formative book for me. Published in 1989, I read it at my midlife, at a time when much was changing for me both personally and professionally. The women she wrote about were exemplars for lives that were fully developed. Yet, each was composed, balanced, on the demands of family, career, and society. Near the end of the book, this sentence stood out: "I could begin to sort out the need to live in an imperfect world from the need to maintain a vision of a better one."1^(p210)

Living an imperfect life, in an imperfect world, happens to most of us. Acknowledging and coming to terms with harms done to others through racism, sexism, xenophobia, and all the other ways one can deny the full humanity of our neighbors also require confronting that imperfection. This is as true in healthcare as any other aspect of life. How then should Americans envision a better world in healthcare?

Perhaps, begin by acknowledging there is no excuse for unequal care. Certainly, this must be true in a wealthy society with the resources that the United States has. And yet the United States (US) consistently ranks first in healthcare cost while falling behind most other developed nations in quality of care.2 A better world might ensure that public health systems are funded and that primary care providers, including midwives, nurse practitioners, and physician assistants, are autonomous and accessible in every community. A better world might make that care affordable for everyone, through any of a number of funding models.3

At the same time, provision of care lags wherever teams do not embrace the opportunity to fine-tune relationships with the goal of improving the quality of care. Even the best guideline or policy can only take a team so far. The biases of physicians or nurses can influence or disrupt change by clinging to a more comfortable older model, rather than relying on demonstrated quality improvement tools or evidence-based care.4,5 So too can short staffing, a real concern in the (almost) postpandemic world that currently exists. The lack of interprofessional collegiality can be addressed by improving interprofessional education options and retraining health professionals to develop mutual respect and trust that can lead to a more open consideration of changes to enhance patient care and satisfaction. At the same time, it is essential to recognize and acknowledge that each health profession-nurses, midwives, and physicians-has a separate and equally valuable scope of practice. Teams cannot function at their highest level of productivity and quality when the contributions of some are seen as more important than those of others based on rank or hierarchy.

Each of us needs to own that words matter. When one writes in a chart or speaks with other team members, words matter just as much as when speaking directly to a patient. Suppose, for example, that a client reveals that they identify as transgender. The provider remembers to acknowledge this in speaking and uses the correct pronouns. But as the chart is reviewed, one might notice that "He" states that he is transgender and wishes to be known by this new name. In the very next paragraph, "She" relates "her" history and symptoms. Or in the hospital staff station, one might hear a disparaging comment about how "some people" just want to get attention by claiming that they are trans. Or, no one corrects the clinician who persists in mis-gendering during rounds but claims they would never be disrespectful to someone's face.

Introspection can also lead to an acknowledgment, that in seeking a better healthcare world, that perceptions matter. Poverty and homelessness have been used as tools to blame the poor or homeless for their diet, cleanliness, and lack of access to care. Race has long been used as a marker to avoid dealing with historic, political, and economic injustices. Evidence exists that those perceptions affect how care is provided-to whom pain medicine is offered, for example.6 Is someone drug seeking, or truly in pain? I recall a regulatory meeting as my state implemented a new, rather draconian, reporting law for newborn drug exposure, including marijuana. One public health official from a wealthy suburb stood up to assure us that, of course, no health officer would object to being turned away at a mandatory random home visit if mother and infant were sleeping. The response from social work staff in the urban areas with high poverty levels was loud, angry, and clear; that perception was rooted in assumptions about the power of families to defend themselves that was not shared by those whose clients were in the greatest need of support.

All of this is to say that the world is imperfect. We have an opportunity to do better, by choosing words that are inclusive rather than discriminatory, building toward collegial and collaborative working environments, and considering how to provide the best care to the greatest number can affect that world for the better.

-Jan M. Kriebs, MSN, CNM, FACNM

Adjunct Professor

Midwifery Institute at Jefferson University

Philadelphia, Pennsylvania

References