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PubMed1976

Social theory and medicine.

Three sociolgists-Talcott Parson, Eliot Freidson, and Mechanic-have explained medical phneomena within a broader theoretical framework. Although all three have made significant contributions, their conclusions remain incomplete on the theoretical level and seldom have been helpful for workers concerned with ongoing problems of health care. Our purpose here is to summarize some of the strengths and weakness of each theoretical position. Parsons has elucidated the sick role as a deviant role in society, the function of physicians as agents of social control, and the normative patterns governing the doctor-patient relationship. The principal problems in Parsons' analysis center on an uncritical acceptance of physicians' social control functions, his inattention tot the ways in which physicians' behavior may inhibit change in society, and overoptimism about the medical profession's ability to regulate itself and to prevent the exploitation of patients. Viewing medical phenomena within a broader theory of the professions in general, Freidson has formulated w wide ranging critique of the medical profession and professional dominance. On the other hand, Freidson's work neglects the full political implications of bringing professional autonomy under control. Mechanic's coceptual approach emphasizes the social psychologic factors, rather than the institutional conditions, which are involved in the genesis of illness behavior. Mechanic also overlooks the ways in which illness behavior, by permitting a controllable from of deviance, fosters institutional stability. In conclusion, we present a breif overview of a theoretical framework whose general orientation is that of Marixian analysis. Several themes recur in this framework: illness as a source of exploitation, the sick role as a conservative mechanism fostering social stability, stratification in medicine, and the imperialsm of large medical institutions and health-related industries.

Clinical Competence↗
PubMed1991

Stratification and standards: a quality assurance perspective. Presidential address.

A diminished public respect for physicians, a decrease in professional autonomy, and an increased regulatory presence have led to extensive changes in medical practice in the past 25 years. Along with rising costs of medical care, there has been a resurgence in interest in the quality of health care, and a considerable body of literature on the monitoring and evaluation of health services has been produced. Quality assurance programs frequently evoke negative and skeptical responses from many physicians for a variety of reasons. Crucial to the potential effectiveness of quality assessment methods is the setting of standards. Physician clinicians should be strongly encouraged to participate directly and seriously in the development of standards. The quality assurance process should be viewed by physicians as an opportunity to recapture the control of the profession and to demonstrate to patients, in an objective manner, the legitimate high quality of care rendered.

Humans↗
PubMed1993

Task Force on Health Care.

The five leading issues identified, in order of importance, were 1. The need for treatment outcome and efficacy data. 2. The need for changes in clinical and academic preparation of entry-level practitioners. 3. The lack of inclusion or use of services for communication and related disorders in public and private health care programs. 4. The need for greater professional autonomy within the health care system. 5. The need to improve services to underserved populations with communication and related disorders. This report was forwarded to key National Office staff and appropriate ASHA boards, councils, and committees for the purposes of determining its feasibility and developing a national plan for action. The feasibility and action plan will detail completed, ongoing and future activities of the Association related to each issue, recommendation, and strategy. Periodic review of the actions taken and progress achieved will be monitored by the Executive Board, other appropriate boards and councils, and designated National Office staff. The plan represents a progressive view of needed change for the professions of speech-language pathology and audiology within the context of the broader health care delivery system.

Audiology↗
PubMed1992

Rural community and physician perspectives on resource factors affecting physician retention.

This study was undertaken to investigate issues affecting recruitment and retention of physicians in a rural north Florida community. As part of this investigation, the authors examined the relevant context of medical care and physician practice for this community. The results identify a number of problems not uncommon in rural communities and supported by previous literature. Physicians felt isolated, dissatisfied with job security and professional autonomy, and frustrated by a lack of cooperation among the major providers of health care. More importantly, upon closer scrutiny, some of the most appealing characteristics of this community for incoming physicians become its weaknesses. Access to a regional medical center nearby and nearness to a metropolitan area were both cited as positive attributes to their choice of practice location. In this community, however, these appear to have resulted in a highly divided medical system. Many of the employed and insured patients in the county prefer to get their medical care in the nearby city. At the same time three separate entities within the community--a federally funded community health center, a county public health unit, and a community hospital--are expected to provide services for the poor and uninsured. The resulting lack of a comprehensive approach to provision of services contributes significantly to the dissatisfaction among providers and to their ultimate retention.

Area Health Education Centers↗
PubMed1997

The cautious acceptance of informed consent in Japan.

The Japanese medical profession has come under increasingly intense scrutiny from the media and the public. Calls for recasting the traditional paternalistic doctor-patient relationship have become sufficiently pervasive that the medical profession itself has accepted the need to incorporate "infomudo konsento" (the English term is commonly used, for lack of a satisfactory phrase in Japanese) into medical practice. The medical establishment is attempting to accomplish this endeavor in a tamed and "Japanized" form which preserves professional autonomy. This paper attempts to illuminate the distinctive tenacity of Japanese medical paternalism. First, the paper presents a descriptive model of cultural paternalism characteristic of traditional Japanese medicine, taking as examples four specific practices: concealing from patients the diagnosis of cancer; withholding from patients information about drugs; requiring patients to sign waivers of rights; and refusing patients access to their own medical records. Second, the paper describes how the economic structure of Japanese health care reinforces these cultural proclivities toward paternalism. Third, the paper explores the paradox of the legal system's treatment of informed consent issues. The paper then addresses the sources of a gradual transformation in attitudes concerning informed consent. Emphasis is given to transformative forces peculiar to Japan: the controversy over brain death and organ transplantation, in which the rhetoric of informed consent has come to be used by all parties as a weapon of convenience and the enforcement (amidst publicity surrounding deaths from experimental drugs and international pressures for drug exports to meet accepted standards of biomedical ethics) of rules requiring informed consent in clinical trials of investigational drugs. The paper finally assesses the impact of the 1995 report of the prestigious Study Commission on Informed Consent.

Cross-Cultural Comparison↗
PubMedDate not supplied

Clinical guidelines: attitudes, information processes and culture in English primary care.

The application to clinical medicine of evidence-based clinical guidelines is an increasingly international policy prescription, yet research on how such guidelines might be implemented has tended to focus on change initiatives without seeking to understand change processes. This paper reports an empirical study of guideline implementation in UK general practice. Most GPs welcome guidelines as a means of improving care, though have reservations about their authority, relevance and effect on professional autonomy. 'Clan' organizational culture predominates and general practices do not generally have well-functioning internal arrangements for the management of clinical evidence and related information. We found no coherent relationships between these variables and practices' actual uptake of guidelines.

Attitude of Health Personnel↗
PubMedDate not supplied

Rehabilitation nurses working as collaborative research teams.

Rehabilitation nurses conducting research would benefit from working within collaborative research teams. The development of intradisciplinary (one discipline) and interdisciplinary (many disciplines) research teams is described in this article. A research team is defined as more than a single person in the role of the researcher while studying the same topic of interest in a joint or collaborative manner. Strategies to ensure successful research team collaboration are described. Exemplars of developing and maintaining a team at one site, which consists of members of the same discipline, as well as another team that consists of multiple professional disciplines, are shared. Collaboration among research team members in practice, administration, and education settings transcends degrees and roles to make substantial contributions to professional practice.

Attitude of Health Personnel↗
PubMed2005

Maintaining psychology's scientific and professional credibility and ethical responsibility to self-regulate: a comment on "validations" of mental health assessment instruments.

Recent growth of "managed" mental health care in the United States has spawned huge demand for products that draw on one of psychology's most well developed subdisciplines, tests and measurement. The commercial potential of mental health assessment instruments intended for widespread use, to meet what Kraus, Seligman, and Jordan (this volume) describe as "an industry-wide surge in outcome evaluations in naturalistic ... settings," necessarily raises conflict of interest dilemmas for those who develop and market them. The American Psychological Association has devoted intensive effort to the preceding issue as it pertains to other aspects of the science and practice of clinical psychology. Comparable attention has not been focused recently on the development and marketing of assessment instruments. This Comment highlights the issue and suggests types of self-regulatory actions that might be taken, e.g., requiring and publishing full disclosure statements of authors' relationships to companies that market instruments like the Treatment Outcome Package in psychometric articles in which they are evaluated.

Conflict of Interest↗
PubMed1982

The effect of centralized decision-making on work satisfaction among nursing educators.

The relationship between work satisfaction and centralization of organizational decision-making was examined using survey data from faculty members at four baccalaureate degree schools of nursing, supplemented by interviews with the deans. In a multiple regression analysis, centralization was a significant predictor of satisfaction (p less than .01), with other relevant variables controlled. In tests for statistical interaction, the effect of centralization on satisfaction did not depend on the strength of faculty members' desires for professional autonomy. The results suggested the potential benefits of changes in organizational decision-making to increase faculty participation.

Decision Making↗
PubMed2005

Reasonable partiality in professional ethics: the moral division of labour.

Attention is given to a background idea that is often invoked in discussions about reasonable partiality: the idea of a moral division of labour. It is not only a right, but also a duty for professionals to attend (almost) exclusively to the interests of their own clients, because their partial activities are part of an impartial scheme providing for an allocation of professional help to all clients. To clarify that idea, a difference is made between two kinds of division of labour, a technical one and a social one. In order to assess the applicability of the idea of a moral division of labour to professional ethics, journalism is contrasted with other professions.

Confidentiality↗
PubMed2001

Towards a research programme for ethics and technology.

In this editorial contribution, two issues relevant to the question, what should be at the top of the research agenda for ethics and technology, are identified and discussed. Firstly: can, and do, engineers make a difference to the degree to which technology leads to morally desirable outcomes? What role does professional autonomy play here, and what are its limits? And secondly, what should be the scope of engineers' responsibility; that is to say, on which issues are they, as engineers, morally obliged to reflect? The research agendas proposed by the authors contributing to this special section, implicitly, give different answers to these questions. We suggest that an explicit discussion of these issues would greatly help in constructing a common research agenda.

Engineering↗
PubMed1982

Abortion and informed consent requirements.

Supreme Court decisions have liberalized a woman's right to decide whether to obtain an abortion. Some state and local governments have tried to circumvent these decisions by enacting requirements designed to discourage abortions by, among other things, dictating to physicians an elaborate litany of specific information that must be communicated to a patient as a necessary precondition of her informed consent for an abortion. This article discusses the legal status of such requirements, their implications for the professional autonomy of physicians, and the role of the medical profession in challenging these restrictions, on its own behalf and in concert with its patients.

Abortion, Legal↗
PubMed1994

The role of national quality registers in the Swedish health service.

This article reports on a quality movement in Sweden that has gone largely unnoticed, namely the national quality control registers. These registers represent a potentially important primary data source for comparative studies and can play an important role in a national strategy for control and improvement of health care quality. First, we review the recent health care quality initiatives in Sweden and the background of national quality control registers. Secondly, we discuss our findings from a study on the purpose, content, value and problems associated with the registers. Our findings are based on (a) interviews with physician managers of the registers, (b) questionnaires to selected hospital departments participating in the registers and (c) questionnaires to elected officials and administrators representing the local health care providers. Finally, we discuss several crucial issues related to the registers. Although some have existed for several years, the registers are still defining their roles. Traditionally, this activity has been managed by the medical profession. However, interest in register information is increasing among health care policy makers and administrators at all levels in the system. Two key issues concern register ownership and finance, but the most sensitive issue concerns the right of policy makers and the public to access register information. The registers and the information they contain illustrate the ongoing conflict between openness and consumer sovereignty in health care on the one hand and professional autonomy on the other.

Cost-Benefit Analysis↗
PubMed1987

Social policy and professional self-interest: physician responses to DRGs.

Prospective hospital reimbursement based on Diagnosis Related Groups (DRGs) began in 1983 for Medicare patients, and many states are adopting similar systems for Medicaid recipients in an attempt to curb rising health care costs. Because of their unprecedented intrusiveness compared to previous cost-containment measures and because they explicitly introduce financial incentives to reduce services, DRGs have great potential to affect health care delivery. To determine the effects of DRGs on hospitals and physicians, six months of ethnographic fieldwork was carried out on the medicine and pediatrics services of a university-affiliated hospital during the first year of DRG-based reimbursement. Observations and interviews were used to discern institutional responses to DRGs and physician knowledge of, experience with, and reactions to this cost-containment effort. Our findings indicate that the hospital instituted many changes to protect its interests. Data gathered from patients' abstracts suggest providers are successfully dealing with the new system; the average length of stay for Medicare patients was reduced by 38% in the first year of prospective reimbursement, compared with a 15% reduction for other patients (P less than 0.05). As a group, the physicians made no organized effort to educate themselves about the new cost-containment regulations. Their knowledge of DRGs was vague and included many misconceptions. Their response was not a coherent one taking broad social concerns into account. Cost-containment was viewed negatively, as a threat to the financial integrity of the hospital, patient care, and professional autonomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗
PubMed1989

Differences in the approaches of the doctor, manager, politician and social scientist in health care controversies--hospital case-mix management methods: an illustration of the manager's approach in health care controversies.

Resource allocation methods in health care are one of the major sources of controversies between managers, doctors, politicians and social scientists. In the past 10 years, an important innovation has appeared in hospital management and payment methods: case based systems, the most well known being the Diagnostic Related Group (DRG), that have been used for 5 years by Medicare in the U.S.A. to pay for hospital care. Through the analysis of the diffusion of DRGs in the U.S.A. and in France, we support the idea that DRGs are a typical illustration of the managerial approach to health care. They represent a significant breach in professional autonomy through the introduction of bureaucratic rationality. We also show how scientific controversies are structured by the dynamics of the diffusion of case based management systems.

Analysis of Variance↗
PubMed1989

Perceptual correlates of physician referral to physical therapists: implications for role expansion.

From an interprofessional role boundary maintenance perspective, this paper traces the historical development of physical therapy relative to physicians. Then, using survey data of 206 physicians in a metropolitan area of the United States, two hypotheses are tested regarding the prospects of physical therapy expanding its role to include highly autonomous skills. The first, from a set of structural-functionalist assumptions about role differentiation, posits that role expansion will precede status enhancement. The other, from conflict-theory assumptions about status politics, posits the opposite. A panel of physical therapists rated 24 procedures as requiring high, moderate and low skills. There was no significant difference in frequency of physician referral for the three levels; referral was associated with patient needs rather than physicians' perceptions of practitioner competency and status. The structural-functional hypothesis was supported, and two policy implications are noted: (1) an expanding physical therapy role is not likely to stimulate 'turf battles' with physicians, and (2) currently, greater professional autonomy is likely to be acquired by physical therapists making physicians aware of the extent of therapists' capabilities (role expansion), rather than through legislating more stringent curricular and license standards (status enhancement). The study is preliminary due to a small response rate.

Humans↗