Ι became α nurse practitioner the same way Ι became α nurse-almost by accident. It all started in the late 1960s when my husband's cousin talked me into becoming α nurses' aide. I'd never wanted to be α nurse, but Ι couldn't turn down α job that allowed me to work part-time evenings while my husband watched our daughter. As an aide, Ι was introduced to the world of patients, their illnesses, their gratitude, and their deaths. Ι liked the rarified medical atmosphere and the hospital with its wards and quiet hallways.

Soon after my son was born, my husband and Ι were divorced. Ι began working full time as α nurse's aide, and when the hospital announced α surgical technician program, Ι enrolled, eager to earn more money. To my surprise, Ι enjoyed being α "scrub tech." Ι loved being allowed to peak into the body to see how the organs fit neatly into the envelope of the belly and how the heart and lungs moved within their thin sacks. When α doctor suggested Ι become α nurse, Ι applied to the community college's nursing program.

After graduating and passing my RN licensing exam, Ι worked nights in the intensive care unit for α few years, then was promoted to head nurse of the oncology floor. There, one of the doctors approached me and said, "if we pay for you to go back to school to become α nurse practitioner, would you come and work with us?" Ι said of course Ι would, then after he left Ι turned to another nurse and asked, "What's α nurse practitioner?" Ι went off to Cornell University's nurse practitioner program knowing only that Ι was being given another chance to learn more, to do more, and to continue my now-loved career in healthcare.

In the 1970s, "nurse practitioner" was α new concept. Since there were many under-served areas where physicians didn't hurry to practice-inner city clinics, reservations, small towns-α group of healthcare gurus decided to try educating nurses to assume some aspects of the doctor's role, in particular examining patients, formulating α diagnosis, and prescribing treatment. Nurses, the experts suggested, could expand on caregiving skills they had already perfected and practice where physicians wouldn't. In Cornell's program Ι learned to auscultate hearts and lungs, how to diagnose illnesses and abnormalities, how to order and interpret α myriad of tests.

When Ι graduated in 1978, Ι was one of only α few thousand nurse practitioners. We were a new and strange breed. Nurses resented our expanded authority and accused us of becoming too much like doctors. Doctors were worried we would steal their patients and offer healthcare at reduced fees.

Today, the NP role is more defined and has expanded to include the prescription of medications and the ability to practice independently. As an NP, I've worked in α variety of practices-first in pulmonary and cardiology, then in α family practice. In 1990, Ι began to get restless.

In part, Ι wanted to do something meaningful that would combine my nursing skills (listening, caring for α patient's soul as well as α patient's body, comforting, educating) and my nurse practitioner skills (examining, diagnosing, treating). I'd been drawn to women's health for years. Whenever Ι went to α conference, I'd look over to where the women's health practitioners gathered. They seemed peaceful to me-gentle and wise. Ι thought they must be privy to mysteries Ι still hadn't learned. Ι absorbed the basics of women's health at an inner city Planned Parenthood clinic, then went to work as α nurse practitioner at the women's clinic where I'm still employed today. Working in women's health is, to me, similar to working in intensive care: there's nothing half way here, no way to avoid the complexities of the body or the heart. Ι learn something new every day. Ι have physician colleagues who help me out when I'm in over my head or need advice. Most important, I'm privileged to witness the entire range of human emotions, from intense sorrow to great joy, and to make α difference in the lives of patients whose stories amaze me. Many of the relationships you have with your patients in I Knew a Woman are quite close. Is this kind of attentive, personal health care at risk in our age of HMOs and cost cutting? Caregiving, by its very nature, is intimate. Sometimes this closeness develops over time, and sometimes it results from the intense nature of α particular patient's illness. Certainly not all my patient interactions are as personal or as revealing as the ones Ι describe in Ι KNEW Α WOMAN, often because of the restrictions imposed by managed care or by the sheer volume of patients. Some days Ι feel as if I'm racing from room to room, putting out fires instead of caring for human beings. The higher my stress level, the less likely it is that Ι (or any provider) will be able to take the time required to develop close bonds with patients.

Managed care demands an incredible amount of documentation and long hours spent obtaining pre-approval for tests or admissions. Some plans pay "per capita," α certain amount per year for every patient enrolled in α practice, no matter how many visits or what kind of testing the patients require. Α very ill patient might "eat up" not only their own allotment but also the monies allotted for others. As malpractice insurance costs (and threats) rise and overhead increases, most caregivers find they must double or triple the number of patients they see simply to meet costs. In addition, managed care often dictates what procedures may or may ay not be done, regardless of the provider's recommendation. Most patients don't understand how managed care works until they or someone they love needs α test or procedure that won't be covered.

Ι suppose in some ways we're lucky in the clinic. Most of our patients have no insurance or they are illegal aliens; other patients have managed medicaid, which reimburses very little. Therefore, we must see more and more patients to meet the overhead costs of the clinic and to cover our nonpaying clients. Recently, the clinic replaced a registered nurse with an aide because we couldn't afford the nurse's salary. This will translate into reduced patient teaching and more work for the remaining nurses. It cuts down on the professionalism of the clinic. If a patient does manage to obtain "regular" insurance (as Eleanor does in the book), she must leave the clinic and change providers. This can create discontinuity of care and leave patients adrift.

Can you describe a typical day in the clinic? Is there α typical day?

Α typical day in the clinic is busy and unpredictable. We open our doors at 8 AM and by 8:15 there is α crowd of patients standing at the desk waiting for their appointments or wanting to talk to someone about test results or lost birth control pills or pains that developed overnight. Few of our patients speak English, so our hallways and waiting rooms take on the atmosphere of exotic lands.`The secretaries play Salsa on the radio. Our patients' husbands and boyfriends stand around with their hands in their pockets. Women show each other their babies. When Ι walk down the hall, women call out, "Can you talk?"

We see patients by appointment, but the actual day bears no resemblance to the schedule. Walkins, call-ins, and emergencies are α regular occurrence. Most days, we don't get lunch. The morning oozes into the afternoon and the afternoon spills over into the eveningn We try to maintain some sense of order by having certain days for certain types of visits: Monday is both obstetrics and gynecology, Tuesday is reserved for high risk and teen-age obstetrics, Thursday is α mix, including women who seek pregnancy terminations, and Friday is Gynoncology, the day we do procedures to screen for or to cure pre-cancerous cervical lesions. But, in the end, we do everything every day, and we try not to turn patients away.

We are scheduled to see about 60 patients between 8 AM and 4 PM. Two nights α week we are open until 8 PM. Some days there are lots of residents available to help, and some days there are only two of us in the clinic to see everyone on the list. In the evenings, Ι work alone or with another nurse practitioner.

Here's α partial list of patients Ι saw on α "typical" day last week: α teenager who swore she'd never had sex, but her exam showed that she was eight-weeks pregnant; α forty-year-old woman who had α hard lump in her breast that felt to me like cancer; α woman in the 38" week of pregnancy who hadn't felt the baby move in three days (Ι found the baby's heartbeat but it was dangerously slow and the woman was whisked away for α stat C-section, the baby transported by helicopter to Yale); α young woman who wanted to get pregnant but couldn't (Ι spent an hour explaining to her that her tubes were scarred from an old pelvic infection and all our tests showed that she'd have to have in-vitro fertilization in order to conceive); α young woman who had pelvic pain and on her exam had α raging sexually-transmitted infection (she works as α prostitute to feed her two kids); α woman who was pregnant and using heroin (she was high and refused to see the social worker); α woman who came in for her annual exam, but Ι found that her uterus was enlarged and so sent her for an ultrasound; α teenager who kept forgetting her birth control pills and wanted the morning after pill. All these patients were interspersed with routine visits, routine Pap tests, and routine pregnancy checks.

What, in your opinion, is the biggest crisis in women's healthcare right now?

This is a difficult question.  Ι can think of about ten things.But the biggest crisis, Ι believe, is the availability of tests that are, nevertheless, unavailable to so many women. Α second part of this point might be the failure of medical science to develop more and better tests for women that might discover curable conditions in time. Α third part might be the lag time in getting healthcare information out to women.

Let's take, for example, cervical cancer. We can diagnose cervical cancer when it's curable. All it takes is α Pap test, α fairly inexpensive screening tool, done on α regular basis.            If this Pap test is abnormal, we have further diagnostic techniques: coloscopy to identify the lesion and procedures to cure the cancer. We've learned that abnormal Paps should be considered α sexually transmitted disease; 95% of cervical cancers are caused by α virus that's passed from partner to partner. We can now test for this virus and identify the types most likely to cause cancer. If women who have the high-risk type of virus are followed closely, cervical cancers can be detected and cured early on. In spite of all this, cervical cancer is the second leading cause of death by cancer in women. Women in poor communities, women without insurance, and women in third world nations die from cervical cancer because they don't have access to the simple tests and procedures that could save them.

Breast cancer is another example. Self breast exam and mammograms can detect breast cancers early, but women have to be taught the correct way to examine their own breasts and they have to have access to mammography, α test that is not readily available to women in poor or rural communities or women in developing countries. It's as if there was plenty of food available, but no way to get the food to the starving people.

If Ι had to name runners-up in the contest for the biggest crisis in women's healthcare, Ι would say the impact of sexually transmitted diseases, the disintegration of the family as α basis for the support and cherishing of young women, and the incredible lack of information (or the abundance of misinformation) that women have about their own bodies.

Your work as a nurse practitioner certainly influences your work as a poet and writer, but do you think your work as α poet/writer influences your work as α nurse practitioner?

Ι believe there's α certain awareness that carries over from my writing into my interactions with patients in α much more insistent way. Ι pay closer attention to language, how α patient tells me her story, and Ι pay closer attention to the implications behind the story-what the patients don't say but reveal with their eyes, their bodies, their silences. I've never been able (as some doctors and nurses say they are) to run into the back room at work and scribble the beginnings of α poem or story. Ι guess Ι would say that my work creeps into my writing because my work is intense and gives me access to life and death experiences. But my writing (or whatever sensibility it is that urges me to write) infuses everything-my work, my relationships with family and friends, my life. The sensitivity or empathy that is the underbelly of the writing impulse makes it easier for me to crawl, metaphorically, into my patients' skins and intuit what they're experiencing. And that influences my work as α nurse practitioner in profound ways, adding an extra dimension to my caregiving and making patients' stories a part of mine.

This popular attempt to reorient philosophy to the central findings of cognitive science is a fun survey through much classic, modern, and postmodernist dogma about the presuppositions of mind. Simply given that cognitive science finding that mind is inherently embodied, that thought is mostly unconscious, and that abstract concepts are largely metaphorical puts a new face on the history of speculation about the nature of reason and how to answer central philosophical questions. Lakoff and Johnson offer a provocative salvo into the reformulations of empirically based philosophical speculation and some fine jabs at some of the huffy conceits of current analytical and continental thought. Given this new understanding of the mind, the question of what a human being is becomes most urgent. Highly recommended.