Search PubMed⌕ Search

Biomedical subjects

J D Stoeckle

Publications and source records attributed to J D Stoeckle.

17 recordsLinked to original sources
PubMed1992

The corporate organization of hospital work: balancing professional and administrative responsibilities.

The development of the hospital into a corporation has influenced the care of patients and the work of the professional staff. As a corporate enterprise, the modern hospital has a private agenda aimed at increasing growth and efficiency with an emphasis on technical services, professionals as employees, and patients as customers. These changes have resulted in a decrease in trustee and professional authority and an increase in administrative control. This shift in the control structure has continued in response to the need for accounting and regulation of services and in response to demands for increased growth and efficiency made by an increasingly competitive market environment. Strategies for the reorganization of hospital staff aimed at improving both inpatient and outpatient care are reviewed. The reorganization of the institution and staff, using either a staff group-practice corporation or an administrative staff model, is proposed. Clinicians have new responsibilities for developing collective arrangements for institutional governance, for allocating institutional resources, for providing public accountability regarding the use of these resources, and for defining the missions of care.

Commerce↗
PubMed1992

An experimental ward. Improving care and learning.

The rapidly changing health care system is still largely organized according to old, and increasingly outdated models. The contemporary demands of patient care and residency training call for an experimental ward, which can develop and test new techniques in hospital organization and the delivery of care in a comprehensive way.

Health Services Research↗
PubMed1991

Advance directives for medical care--a case for greater use.

UNLABELLED: BACKGROUND. Advance directives for medical care and the designation of proxy decision makers to guide medical care after a patient has become incompetent have been widely advocated but little studied. We investigated the attitudes of patients toward planning, perceived barriers to such planning, treatment preferences in four hypothetical scenarios, and the feasibility of using a particular document (the Medical Directive) in the outpatient setting to specify advance directives. METHODS: We surveyed 405 outpatients of 30 primary care physicians at Massachusetts General Hospital and 102 members of the general public in Boston and asked them as part of the survey to complete the Medical Directive. RESULTS: Advance directives were desired by 93 percent of the outpatients and 89 percent of the members of the general public (P greater than 0.2). Both the young and the healthy subgroups expressed at least as much interest in planning as those older than 65 and those in fair-to-poor health. Of the perceived barriers to issuing advance directives, the lack of physician initiative was among the most frequently mentioned, and the disturbing nature of the topic was among the least. The outpatients refused life-sustaining treatments in 71 percent of their responses to options in the four scenarios (coma with chance of recovery, 57 percent; persistent vegetative state, 85 percent; dementia, 79 percent; and dementia with a terminal illness, 87 percent), with small differences between widely differing types of treatments. Specific treatment preferences could not be usefully predicted according to age, self-rated state of health, or other demographic features. Completing the Medical Directive took a median of 14 minutes. CONCLUSIONS: When people are asked to imagine themselves incompetent with a poor prognosis, they decide against life-sustaining treatments about 70 percent of the time. Health, age, or other demographic features cannot be used, however, to predict specific preferences. Advance directives as part of a comprehensive approach such as that provided by the Medical Directive are desired by most people, require physician initiative, and can be achieved during a regular office visit.

Advance Directives↗
PubMed1991

Teaching medicine as a human experience: a patient-doctor relationship course for faculty and first-year medical students.

We developed a required, longitudinal course for first-year medical students that addressed the patient-doctor relationship. Our course linked understanding patients' experiences and perspectives on illness with listening to, talking with, and establishing a rapport with patients while obtaining their medical histories. Learning was enhanced by use of an interdisciplinary faculty and by small-group continuity and faculty mentoring. Our curriculum adapted problem-based, self-directed educational methods to convey medical humanism. We focused on bedside interviewing as the means for exploring patients' social, emotional, and ethical concerns.

Attitude of Health Personnel↗
PubMed1979

Inpatient performance of primary care residents: impact of reduction in time on the ward.

The inpatient (ward/intensive-care-unit) performance of primary care medical residents was compared with that of their peers in the standard internal medicine residency program. The primary care residents spent half as much time on inpatient rotations as did their peers in the first two years of training. History-taking, physical examination, case presentation, record-keeping, patient management, and overall performance were assessed and scored by the attending physicians using the American Board of Internal Medicine's Clinical Performance Evaluation Form. The performances of the two groups were nearly identical, suggesting that substantial time in the first two years of residency can be devoted to ambulatory training without markedly compromising development of acute care skills.

Clinical Competence↗
PubMed1977

Graduate education in primary care: an economic analysis.

To determine the financial requirements of an established primary-care educational program for house officers, we studied two prepaid and two fee-for-service Harvard Primary Care Program affiliated practices. Program-wide, each resident saw an average of 112 patients per month, with patient service costs of $2,580. With teaching and administrative expenses included, total monthly costs averaged $3,120 and $3,270 per trainee for prepaid and fee-for-service practices respectively. In fee-for-service practices, resident billings for patient services averaged $2,790, yielding revenues of $2,510 per month, which offset 77 per cent of total program costs. At current reimbursement rates, covering full program costs in the fee-for-service practices would require an increase of more than 40 per cent in resident-provided patient-care volume. By reducing time available for broad ambulatory experiences, such an increase would necessitate substantial program restructuring and limit opportunities for innovation in the Harvard Primary Care Program.

Costs and Cost Analysis↗
PubMed1977

Pelvic examination instruction and the doctor-patient relationship.

Nonphysician women instructors from a women's health center taught the pelvic examination to second-year Harvard Medical School medical students. They demonstrated the procedure and acted as subjects for the students' examinations. In addition to teaching standard techniques, the instructors showed how the patient could be offered explanation of the procedure and information about her health during the performance of the examination. The exercises are described in terms of their implications for teaching the doctor-patient relationship during physical examination instruction. The following aspects are discussed: the use of nonphysicians as "practical instructors," improving attitudes toward women and promoting patient autonomy, and redefining aspects of the student-patient relationship in clinical training.

Anxiety↗
PubMed1975

Residency training in primary care internal medicine. Report of an operational program.

The Primary Care Program at the Massachusetts General Hospital is designed to develop competence in the full range of problems encountered by general internists delivering primary care. House staff spend 3 years in the program, which starts with internship, includes a senior residency, and fulfills the requirements for board eligibility in internal medicine. Half of the training is provided in outpatient care settings. House staff assume responsibility for organization and operation of an ambulatory medical unit. In addition, there is supervised instruction in office gynecology, orthopedics, ear, nose and throat, dermatology, and psychiatry. Close integration with the traditional inpatient-oriented training program is maintained to ensure commensurate growth and competence in management of acute, life-threatening disease.

Boston↗
PubMed1975

New organizations out of old ones: teaching group practices out of private practice and outpatient departments.

A private group practice and a traditional hospital medical clinic are joined together as a teaching group practice for primary care (Internal Medical Associates). Responsible for revenues as well as costs, the practice is administered by a board of managers composed of physicians, nurses, and administrators in the practice. This decentralization of practice from the clinical department and hospital administration has resulted in (1) a reduction in the numbers of physicians needed for the practice, (2) a greater visit census with increased physician productivity, and (3) a reduced operating deficit and better understanding of transient and educational costs. The matrix organization of the board of managers has resulted in better communication and a commitment of the staff to common goals. Public demand for a single standard of care for patients of all backgrounds, professional aspirations to work in groups, and educators' interest in training outside the hospital converge to make such reorganizations of practical necessity.

Ambulatory Care↗
PubMed1975

The compensation experience of patients with chronic beryllium disease.

The experience of patients with chronic beryllium disease seeking workmen's compensation indicates that the system does not meet its intentions of providing for relief of workers for job-related illness. In the instance of beryllium disease there is undue delay in adjudication of the compensation. This delay has its origin in part from litigation over the diagnosis and disability on the part of private insurers and in part on failure of the IAB to press for findings. Moreover, the process of litigation and delay may produce significant psychological distress. For others the compensation for a chronic disability is inadequate. Whether compensation acts as a system of relief depends on whether the patient has a working husband or wife. Among the women here with beryllium disease, the system worked only to the extent that they could rely on their husbands. Compensation benefits should be provided in accord with rises in the cost of living index. Compensation boards should press for prompt settlement of claims.

Adolescent↗